1. A 70-year-old woman has had increasing abdominal pain over the past 2 days. She has renal failure and has been receiving peritoneal dialysis for 18 months; her last treatment was 2 hours ago. She appears toxic. Her temperature is 39 C (102.2 F), and blood pressure is 140/90 mm Hg. Her abdomen is distended and diffusely tender to deep palpation with rebound tenderness. Leukocyte count is 18,000/mm3. Which of the following is the most appropriate next step?

A ) X-ray films of the abdomen

B ) Comparison of abdominal fluid amylase with serum amylase activity

C ) Gram's stain of abdominal fluid

D ) Ultrasonography of the abdomen

E ) CT scan of the abdomen and pelvis

2. A 5-year-old girl is brought to the physician because of temperatures to 40 C (104 F), tachypnea, and a nonproductive cough for 12 hours. Four days ago she was treated with an oral antibiotic for suspected pneumococcal pneumonia. Examination shows diminished breath sounds over the lower right lung fields and dullness to percussion at the right costophrenic angle. Which of the following is the most likely diagnosis?

A ) Bronchopleural fistula

B ) Empyema

C ) Lung abscess

D ) Pleurodynia

E ) Pneumothorax

3. A 40-year-old man is brought to the emergency department 1 hour after a high-speed motor vehicle collision. On arrival, he is awake and alert but has severe pain over the sternum. His systolic blood pressure is 80 mm Hg, pulse is 80/min, and respirations are 10/min. An ECG shows multifocal premature ventricular contractions but no ST-segment changes. His PO2 is 100 mm Hg. After 1 L of lactated Ringer's solution is administered, his PO2 decreases to 60 mm Hg while breathing 4 L/min of oxygen by nasal cannula. Pulmonary capillary wedge pressure has increased from 14 mm Hg to 24 mm Hg (N=1–10). Which of the following is the most likely explanation for the patient's poor response to fluid resuscitation?

A ) Inadequate administration of fluids

B ) Myocardial contusion

C ) Myocardial infarction

D ) Pulmonary contusion

E ) Traumatic rupture of the aorta

4. A 21-year-old African American college student has had increasing fatigue over the past 3 weeks. Since an episode of cystitis treated with trimethoprim-sulfamethoxazole 3 weeks ago, he has been unable to keep up with his physical education classes. For 6 months, he has been following a vegetarian diet that has been supervised by student health services. Examination shows no abnormalities. His hemoglobin level is 10 g/dL, mean corpuscular volume is 85 μm3, and reticulocyte count is 15%. Which of the following is the most likely cause of anemia in this patient?

A ) Anemia secondary to infection

B ) Antibiotic therapy

C ) Gastrointestinal blood loss

D ) Sickle cell disease

E ) Vegetarian diet

5. An 87-year-old nursing home resident with dementia, Alzheimer's type, is admitted to the hospital because of progressive lethargy and decreased appetite for 3 days. She had a flu-like illness followed by a deep cough 1 week ago. Over the past 10 months, she has been hospitalized once for bacterial pneumonia. She is responsive only to painful stimuli. Her temperature is 38.6 C (101.5 F), blood pressure is 110/60 mm Hg, pulse is 123/min and regular, and respirations are 28/min. Examination shows dry mucous membranes. There is no adenopathy. Crackles are heard in the right lung base. An x-ray film of the chest shows an infiltrate at the right lung base. The remainder of the examination shows no abnormalities. Which of the following is the most likely predisposing factor for this patient's pneumonia?

A ) Decreased airway elasticity

B ) Decreased baroreflex

C ) Decreased gag reflex

D ) Decreased thyroid function

E ) Diastolic cardiac dysfunction

F ) Impaired cardiac response to exercise

G ) Impaired T-lymphocyte function

H ) Impaired thirst

I ) Increased lung compliance

J ) Renal salt wasting

6. A 27-year-old woman comes to the physician because of feelings of anxiety about attending her 10-year high school reunion. She has a 2-year history of profound anxiety, palpitations, and sweating associated with an uneasiness around people; she avoids family gatherings and visiting friends because she is afraid of being embarrassed. She acknowledges that this fear is unreasonable. She does not use illicit drugs but says that alcohol makes her more comfortable around people. Her blood pressure is 130/90 mm Hg, and pulse is 88/min. On physical examination, she appears healthy and well nourished. Occasional wheezing is heard over the left lung field. The remainder of the examination shows no abnormalities. On mental status examination, she appears worried. Her leukocyte count is 9000/mm3 with a normal differential. Which of the following is the most likely diagnosis?

A ) Alcohol abuse

B ) Anxiety disorder due to a general medical condition

C ) Asthma

D ) Generalized anxiety disorder

E ) Panic disorder with agoraphobia

F ) Social phobia

The response options for the next two items are the same. You will be required to select one answer for each item in the set.

For each patient with urinary incontinence, select the most likely cause.

A ) Detrusor instability

B ) Interstitial cystitis

C ) Overflow incontinence

D ) Stress incontinence

E ) Urethra diverticulum

F ) Urinary fistula

7. A previously healthy 44-year-old woman, gravida 4, para 4, comes to the physician because of a 9-month history of progressive loss of small amounts of urine while running; she now has to wear an absorbent pad. Examination shows a second-degree cystourethrocele.

For each patient with urinary incontinence, select the most likely cause.

A ) Detrusor instability

B ) Interstitial cystitis

C ) Overflow incontinence

D ) Stress incontinence

E ) Urethra diverticulum

F ) Urinary fistula

8. One day after an uncomplicated spontaneous vaginal delivery, a 23-year-old woman, gravida 1, para 1, has the onset of loss of small amounts of urine. She received epidural anesthesia during labor and delivery. Examination shows an episiotomy without evidence of hematoma. She is voiding 50 to 75 mL of urine at a time. Postvoid residual volume is 300 mL.

The response options for the next two items are the same. You will be required to select one answer for each item in the set.

For each patient with cognitive impairment, select the most likely diagnosis.

A ) Acute stress disorder

B ) Dementia, Alzheimer's type

C ) Dissociative amnesia

D ) General paresis

E ) Head trauma

F ) Hepatolenticular degeneration (Wilson's disease)

G ) HIV encephalitis

H ) Huntington's disease

I ) Major depressive disorder

J ) Multi-infarct (vascular) dementia

K ) Niacin deficiency

L ) Normal-pressure hydrocephalus

M ) Parkinson's disease

N ) Pick's disease

O ) Schizophrenia, catatonic type

P ) Normal aging

9. An 82-year-old woman is brought to the physician by her granddaughter because of a 6-week history of increasing forgetfulness. She is a retired schoolteacher and lives independently. Her granddaughter is concerned because on several occasions she has left the stove on when she went to bed. During conversations with her granddaughter, she has difficulty remembering past events and seems unconcerned about her memory lapses. The patient describes trouble sleeping through the night and has had a decreased appetite resulting in a 4.5-kg (10-lb) weight loss over the past month. She has a history of similar symptoms 2 and 5 years ago that were successfully treated with medication. She appears unkempt and has poor personal hygiene. Her temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, and pulse is 80/min and regular. Mental status examination shows psychomotor retardation, a flat affect, impaired ability to recall past events, and trouble repeating three numbers in sequence. She is unable to recall the names of recent presidents. Her serum urea nitrogen (BUN) level is 25 mg/dL, and serum creatinine level is 1.7 mg/dL.

For each patient with cognitive impairment, select the most likely diagnosis.

A ) Acute stress disorder

B ) Dementia, Alzheimer's type

C ) Dissociative amnesia

D ) General paresis

E ) Head trauma

F ) Hepatolenticular degeneration (Wilson's disease)

G ) HIV encephalitis

H ) Huntington's disease

I ) Major depressive disorder

J ) Multi-infarct (vascular) dementia

K ) Niacin deficiency

L ) Normal-pressure hydrocephalus

M ) Parkinson's disease

N ) Pick's disease

O ) Schizophrenia, catatonic type

P ) Normal aging

10. A 42-year-old computer science professor is brought to the physician by her husband, who reports insidious changes in his wife's personality and behavior. He reports that she believes that aliens have been speaking to her and tampering with their heating and air-conditioning systems. He says that she was upset when she turned 40 years old, and her symptoms have developed since that time. She was adopted, and her family history is unknown. Physical examination shows vermicular movements of the tongue and bilateral writhing motions of the upper extremities. Mental status examination shows indifference to her condition and mild to moderate difficulty with memory and calculations.

11. A 5-month-old boy is brought for a follow-up examination. He was born at 37 weeks' gestation and has had persistent wheezing since shortly after birth despite treatment with nebulized and oral bronchodilators and oral corticosteroids. His diet consists of 32 ounces of iron-fortified cow's milk-based formula daily. He appears well nourished and happy. On examination, there is moderate relief of wheezing with extension of the neck. Which of the following is the most likely mechanism of this infant's wheezing?

A ) Allergic reaction to cow's milk

B ) Aspiration of a foreign body

C ) Compression of the airway by a vascular ring

D ) Concurrent upper respiratory tract infection

E ) Persistent immaturity of lungs

12. An 18-month-old boy is brought to the emergency department because he has not used his left arm since he fell while walking and holding hands with his 8-year-old sister 2 hours ago. On examination, he holds his left upper extremity at his side with his forearm pronated. There is no tenderness of the left lower extremity, but there is restricted movement of the elbow. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate initial step in management?

A ) Passive hypersupination of the forearm

B ) Application of figure-of-8 strap

C ) Administration of analgesics and application of ice

D ) Aspiration of the elbow joint

E ) In-place splint immobilization of the elbow

13. A 6-month-old girl is brought to the physician for a routine health maintenance examination. She was born with a lumbosacral myelomeningocele which was successfully repaired at 2 days of age. The anterior fontanelle is 6 x 8 cm and bulging, and the posterior fontanelle is 3 x 4 cm and bulging. She has severe motor and sensory deficits involving both lower extremities. A head growth chart shows the following values:
Age
Head circumference (cm)

Birth
34.2
1 month
36.6
2 months
38
4 months
44
6 months
47

Which of the following is the most likely cause of increased intracranial pressure?

A ) Acute cerebral edema

B ) Decreased absorption of cerebrospinal fluid

C ) Dilation of cerebral arteries

D ) Intracranial mass lesion

E ) Obstruction of lateral sinus

F ) Obstruction of superior vena cava

G ) Obstruction of cerebrospinal fluid flow

H ) Overproduction of cerebrospinal fluid

14. An 18-year-old primigravid woman comes for her initial prenatal visit at 16 weeks' gestation. She is not sure about the date of her last menstrual period but says that the pregnancy probably occurred immediately after she stopped taking oral contraceptives 5 months ago. Maternal serum α-fetoprotein (MSAFP) level is increased to 3 multiples of the median. Which of the following is the most appropriate next step in management?

A ) Repeat measurement of MSAFP level

B ) Triple screening for MSAFP, serum β-hCG, and serum estriol levels

C ) Ultrasonography

D ) Amniocentesis for measurement of α-fetoprotein level

E ) Amniocentesis for chromosomal analysis

15. A 28-year-old man is brought to the emergency department by police because of severe pain in the right lower quadrant of the abdomen for 36 hours. He has been incarcerated in the county jail, and his court hearing is scheduled in 12 hours. He takes no medications. Abdominal examination shows no rebound. Complete blood count, liver tests, and erythrocyte sedimentation rate are within normal limits. An x-ray film of the abdomen shows a normal gas pattern. Test of the stool for occult blood is negative. Which of the following is the most likely diagnosis?

A ) Adjustment disorder

B ) Conversion disorder

C ) Depressive disorder not otherwise specified

D ) Factitious disorder

E ) Hypochondriasis

F ) Malingering

G ) Somatization disorder

16. A 6-year-old girl is brought to the physician because of a 4-week history of headache, fatigue, and decreased appetite. During this period, she has had nausea and vomiting. At the age of 4 years, she was diagnosed with poststreptococcal glomerulonephritis. She is at the 15th percentile for height and the 10th percentile for weight. Examination shows no abnormalities. Her serum urea nitrogen (BUN) level is 50 mg/dL. Which of the following is most likely to limit progression of this patient's renal failure?

A
) Increased potassium and sodium bicarbonate intake

B
) Decreased sodium and daily calorie intake

C
) Low-protein diet

D
) Strict fluid restriction

E
) Dialysis

17. A previously healthy 62-year-old man comes to the emergency department because of abdominal pain for 48 hours. His temperature is 38.6 C (101.5 F), blood pressure is 130/80 mm Hg, pulse is 110/min, and respirations are 15/min. Abdominal examination shows diffuse left lower quadrant tenderness with no peritoneal signs. Rectal examination shows no abnormalities; test of the stool for occult blood is negative. His leukocyte count is 14,700/mm3. Which of the following is the most appropriate next step in diagnosis?

A
) Barium enema

B
) CT scan of the abdomen

C
) Colonoscopy

D
) Cystoscopy

E
) Exploratory laparotomy

18. A previously healthy 3-month-old girl is brought to the emergency department because of a 3-day history of grunting and increasing difficulty breathing. She appears ill. Her temperature is 36.7 C (98 F), pulse is 160/min, and respirations are 76/min. Examination shows grunting, nasal flaring, and marked intercostal retractions. Bronchial breath sounds and occasional bilateral crackles are heard on auscultation. Serum studies show:

Ca2+ 5.6 mg/dL
Phosphorus 11 mg/dL
Alkaline phosphatase 250 U/L

Capillary blood gas analysis on 100% oxygen:

pH 7.36
PCO2 38 mm Hg
PO2 46 mm Hg

An x-ray film of the chest shows bilateral, diffuse interstitial infiltrates and absence of the thymic shadow. Bronchoalveolar lavage is positive for numerous Pneumocystis carinii. Which of the following is the most likely mechanism of these findings?

A ) Adenosine deaminase deficiency

B ) Consumption of complement

C ) Defective opsonization

D ) Destruction of CD4+ T lymphocytes

E ) Developmental arrest of maturation of B lymphocytes

F ) Dysmorphogenesis of the third and fourth pharyngeal pouches

G ) Impaired chemotaxis

H ) Impaired phagocytic oxidative metabolism

19. A 4-year-old boy is brought to the emergency department 20 minutes after being involved in a motor vehicle collision. He was an unrestrained passenger. On arrival, his blood pressure is 110/70 mm Hg, pulse is 100/min, and respirations are 32/min with grunting and retractions. Examination shows multiple bruises over the chest. Arterial blood gas analysis while breathing 40% oxygen shows:

pH 7.38
PCO2 34 mm Hg
PO2 66 mm Hg

An x-ray film of the chest obtained 4 hours later shows diffuse infiltrates on the right side. Which of the following is the most likely diagnosis?

A
) Acute respiratory distress syndrome

B
) Aspiration pneumonia

C
) Fat embolism

D
) Hemothorax

E
) Pulmonary contusion

20. A 72-year-old man comes to the physician because of a 7-month history of leg weakness and dry eyes and mouth. He also has had a 10.4-kg (23-lb) weight loss over the past 4 months despite no change in appetite. He has smoked one and a half packs of cigarettes daily for 50 years. He drinks 4 oz of alcohol daily. He has peptic ulcer disease and emphysema. Medications include cimetidine, theophylline, and low-dose prednisone. Examination shows mild ptosis. He has a barrel-shaped chest. Breath sounds are distant. There is moderate weakness of the proximal muscles of the lower extremities. Reflexes are absent. He has difficulty rising from a chair. Sensory examination shows no abnormalities. An x-ray film shows a hyperinflated chest and a 3 x 4-cm mass in the right hilum. His neurologic findings are most likely due to a lesion involving which of the following?

A
) Muscle membrane

B
) Parasympathetic nervous system

C
) Peripheral nerve

D
) Presynaptic neuromuscular junction

E
) Sympathetic nervous system

21. A 42-year-old man comes to the emergency department because of a 2-week history of increasingly severe headaches and a 2-day history of nausea, vomiting, neck stiffness, and unsteadiness. He has type 2 diabetes mellitus treated with glyburide. His temperature is 38.1 C (100.5 F). Funduscopic examination shows bilateral papilledema. Neurologic examination shows mild meningismus and diffusely brisk deep tendon reflexes. He walks with a moderately broad-based gait. He is able to recall two out of three objects after 5 minutes and makes several errors on serial sevens. A CT scan of the head shows no abnormalities. Cerebrospinal fluid analysis shows a glucose level of 18 mg/dL, a protein level of 108 mg/dL, and a leukocyte count of 59/mm3 (1% segmented neutrophils and 99% lymphocytes); a cryptococcal antigen assay is positive. Which of the following is the most appropriate pharmacotherapy for this patient?

A
) Acyclovir

B
) Amphotericin B

C
) Itraconazole

D
) Penicillin

E
) Vancomycin

22. A 3-year-old girl is brought to the physician after her mother noted blood on her underpants. Examination shows genital condylomata acuminata in the perineal, peri-introital, labial, and anal areas. Some of the pedunculated condylomata appear to have caused the bleeding. She has no visible intravaginal condylomata or vaginal or anal tears. Her mother has a palmar wart on her hand but no history of condylomata acuminata. Her mother has a boyfriend who does not live with them and who has never been left alone with the girl. They live with the mother's 27-year-old brother who only baby-sits the children when they are asleep. Which of the following is the most appropriate next step in management?

A
) Psychiatric assessment of the mother

B
) DNA typing of the mother's palmar wart for papillomavirus

C
) Treatment of the mother's palmar wart

D
) Vaginal, anal, and throat cultures for Chlamydia trachomatis and Neisseria gonorrhoeae in the child

E
) Laser therapy of the condylomata acuminata in the child

23. A 55-year-old man has had crushing substernal chest pain on exertion over the past 6 weeks. He had a myocardial infarction 2 months ago. He takes nitroglycerin as needed and one aspirin daily. He has smoked two packs of cigarettes daily for 30 years. Examination shows normal heart sounds and no carotid or femoral bruits. Treatment with a β-adrenergic blocking agent is most likely to improve his symptoms due to which of the following mechanisms?

A
) Decreasing diastolic relaxation

B
) Decreasing myocardial contractility

C
) Dilating the coronary arteries

D
) Peripheral vasodilation

E
) Preventing fibrin and platelet plugs

24. A previously healthy 52-year-old woman comes to the physician because she has had a large pimple on her right hand for 2 weeks that has failed to heal. She resides in southeastern USA where she owns a nursery and garden shop. Examination shows a painless red papule on the hand with several nontender subcutaneous nodular lesions above it. Which of the following is the most likely diagnosis?

A ) Blastomycosis

B ) Candidiasis

C ) Coccidioidomycosis

D ) Histoplasmosis

E ) Sporotrichosis

25. A 28-year-old woman at 28 weeks' gestation reports excessive fatigability and dyspnea. Her blood pressure is 118/74 mm Hg, pulse is 110/min and regular, and lungs are clear to auscultation. The cardiac apex is not palpable. S1 is loud, and there is a sharp sound after S2. A low-frequency diastolic murmur is heard at the apex that increases in intensity before S1. Which of the following is the most likely diagnosis?

A
) Aortic regurgitation

B
) Ebstein's anomaly

C
) Mitral regurgitation

D
) Mitral stenosis

E
) Tricuspid regurgitation

26. A 27-year-old woman comes to the physician because of a 2-year history of intermittent diarrhea and severe cramping abdominal pain. The stools are watery, occasionally foul-smelling, and nonbloody. She is currently pain-free and has not had diarrhea for 2 days. She also has intermittent constipation. She has not had fever or weight loss. She returned from a trip to Mexico 3 months ago. She had an appendectomy at the age of 12 years and a cesarean delivery 4 years ago. Examination shows no abnormalities. Which of the following is the most likely diagnosis?

A
) Bacterial gastroenteritis

B
) Crohn's disease

C
) Intermittent small-bowel obstruction

D
) Irritable bowel syndrome

E
) Laxative abuse

27. An asymptomatic 21-year-old woman is found to have an adnexal mass on pelvic examination. She uses oral contraceptives. A photograph of the mass is shown. Which of the following is the most likely diagnosis?

A
) Benign cystic teratoma

B
) Corpus luteum cyst

C
) Dysgerminoma

D
) Endometrioma

E
) Mucinous cystoadenoma

28. A 16-year-old girl is brought to the physician because of episodes of palpitations over the past 6 months. The episodes occur when she runs or plays basketball. She is otherwise asymptomatic. Her blood pressure is 124/46 mm Hg, pulse is 78/min, and respirations are 18/min. She weighs 55 kg (121 lb) and is 180 cm (71 in) tall. Her arm span is 188 cm (74 in), and the upper segment to lower segment ratio is 0.85. Her fingers appear long and are hyperextensible. A grade 4/6, early diastolic murmur is heard along the upper and middle left sternal border with radiation to the apex. Peripheral pulses are bounding. Which of the following is the most likely cause of these findings?

A
) Aortic incompetence

B
) Aortic stenosis

C
) Mitral incompetence

D
) Mitral stenosis

E
) Pulmonary incompetence

F
) Pulmonary stenosis

G
) Tricuspid incompetence

H
) Tricuspid stenosis

29. A previously healthy 87-year-old woman comes to the physician because of a 4-month history of vulvar itching. Examination shows excoriated areas from scratching and a white, thin vulva. The labia minora are absent, and there are small fissures at the introitus. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?

A
) Escherichia coli infection

B
) Lichen sclerosus

C
) Squamous cell carcinoma

D
) Trichomoniasis

E
) Vulvar melanoma

F
) Vulvar vestibulitis

30. One month after undergoing an uneventful renal transplant for chronic renal failure secondary to glomerulonephritis, a 38-year-old woman is hospitalized because of increased serum urea nitrogen (BUN) and creatinine levels. Prior to transplantation, she had been receiving hemodialysis for 3 years. Current medications include cyclosporine and prednisone. Examination shows no abnormalities. Over the past 48 hours, urine output has remained stable. Both renal biopsy and a radionuclide scan confirm the diagnosis of acute rejection. Which of the following is the most effective treatment?

A
) Immediate discontinuation of cyclosporine

B
) Increased dosage of corticosteroids

C
) Diuresis and alkalinization of the urine

D
) Renal dialysis for 1–2 weeks

E
) Transplant nephrectomy

31. An 18-year-old man comes to the physician 1 week after he had a blood pressure of 140/110 mm Hg during a routine precollege examination. His temperature is 37.1 C (98.7 F), blood pressure is 140/100 mm Hg, pulse is 92/min, and respirations are 12/min. The upper extremities appear to be more muscular than the lower extremities. Radial pulses are normal; femoral, posterior tibial, and dorsalis pedis pulses are decreased. A grade 2/6 systolic murmur is heard over the precordium, anterior chest, and back. An ECG shows left ventricular hypertrophy. Which of the following is the most appropriate next step in management?

A ) Limiting physical activity

B ) Repeat blood pressure measurement in 1 month

C ) Initiate a low-sodium diet and exercise program

D ) Pharmacologic management

E ) Operative treatment

32. A 77-year-old woman comes to the physician because of a 2-day history of cramping abdominal pain and distention accompanied by nausea and vomiting. She is otherwise healthy and has no history of abdominal operations. Her temperature is 37.4 C (99.4 F), blood pressure is 110/86 mm Hg, pulse is 112/min, and respirations are 24/min. Cardiopulmonary examination shows no abnormalities. Examination of the abdomen shows distention and mild diffuse tenderness; bowel sounds are high-pitched. An x-ray film of the abdomen shows air-fluid levels throughout the small bowel and air in the liver; there is no gas in the colon or free air. Which of the following is the most likely diagnosis?

A
) Adhesive small-bowel obstruction

B
) Cecal cancer

C
) Gallstone ileus

D
) Intussusception

E
) Mesenteric infarction

F
) Ruptured appendicitis

G
) Small bowel lymphoma

33. Four hours after undergoing a cesarean delivery at term followed by tubal ligation, a 37-year-old woman, gravida 2, para 2, has dizziness and confusion. The operation was uncomplicated, and blood loss is estimated to be 800 mL. Patient-controlled epidural analgesia has been moderately effective for pain. Her blood pressure now is 80/40 mm Hg, decreased from 120/72 mm Hg intraoperatively, and pulse is 152/min, increased from 96/min intraoperatively. Breath sounds are decreased bilaterally. No murmurs are heard. Abdominal examination shows distention and tenderness. Bowel sounds are absent. The incision is intact with no drainage. She is disoriented to person, place, and time. Her hematocrit is 23%; preoperative hematocrit was 35%. Which of the following is the most likely cause of the hemodynamic changes?

A
) Epidural-related hypotension

B
) Insufficient intraoperative fluid replacement

C
) Postoperative intra-abdominal hemorrhage

D
) Supine hypotensive syndrome

E
) Underestimated intraoperative blood loss

34. A 42-year-old woman comes to the physician for evaluation of persistently increased blood pressures. At her last two office visits during the past 3 months, her blood pressure has ranged between 150–170/105–115 mm Hg. During this period, she has had occasional headaches. In addition, she has had an increased urine output over the past 6 weeks that she attributes to a diet high in sodium. She is otherwise healthy and takes no medications. Her blood pressure today is 168/115 mm Hg, pulse is 68/min, and respirations are 14/min. Funduscopic examination shows mild arteriovenous nicking. The point of maximal impulse is not displaced. There is no edema, abdominal bruits, or masses. Serum studies show:

Which of the following is the most likely underlying cause of this patient's hypertension?

A
) Autonomous production of aldosterone

B
) Catecholamine-producing tumor

C
) Decreased arterial distensibility caused by atherosclerosis

D
) Excess production of atrial natriuretic peptide

E
) Juxtaglomerular cell hypertrophy and sclerosis

35. A previously healthy 4-year-old girl is brought to the physician because of fever and refusal to walk for 1 day. She appears mildly ill. Her temperature is 38.6 C (101.5 F), pulse is 120/min, and respirations are 22/min. The right knee is erythematous and swollen. She holds her right knee in flexion and resists any attempted movement of her right leg. She cries when the right knee is moved. Which of the following is the most appropriate next step in management?

A
) Acetaminophen with codeine therapy

B
) Arthrocentesis

C
) Bone marrow aspiration

D
) Bone scan

E
) Immobilization and traction

F
) Lyme titer

G
) MRI of the spine

H
) Physical therapy

I
) Reassurance

J
) Serum rheumatoid factor assay

K
) Systemic antibiotic therapy

36. An 18-year-old man comes for an examination prior to participation in school sports. He states that he has had a dull ache in the scrotum since being hit in that area during a basketball game 2 months ago. Examination shows a 2-cm, hard, nontender mass in the right testicle. The mass does not transilluminate or change in size when the patient is placed in the supine position. Which of the following is the most likely cause?

A
) Cystic dilations of the efferent ductules

B
) Dilated pampiniform venous plexus

C
) Fluid accumulation within the tunica vaginalis testis

D
) Germinal cell tumor

E
) Vascular trauma

37. A 14-year-old boy is brought to the physician by his parents because of a 2-year history of increasing academic problems. His parents say that he has always been hyperactive and distractible, but now his academic performance has deteriorated to the point that he is failing ninth grade. His teachers say that his hyperactivity is disrupting the classroom. He weighs 54 kg (120 lb) and is 152 cm (60 in) tall. Sexual development is Tanner stage 5; examination shows macro-orchidism, which was not shown on previous examinations. He has a high forehead and long, protruding ears. He exhibits poor eye contact during the examination. Psychoeducational testing shows an IQ of 70. Which of the following is the most likely diagnosis?

A
) Attention-deficit/hyperactivity disorder

B
) Autistic disorder

C
) Down syndrome

D
) Fetal alcohol syndrome

E
) Fragile X syndrome

F
) Lesch-Nyhan syndrome

G
) Pervasive developmental disorder, not otherwise specified

H
) Prader-Willi syndrome

I
) Rett's disorder

J
) Seminiferous tubule dysgenesis (Klinefelter's syndrome)

38. A 32-year-old woman comes to the physician because of vaginal discharge for 2 weeks. She has been sexually active with one female partner for 5 years. She has not been treated with antibiotics over the past 2 years. Her last Pap smear was 6 years ago when she was sexually active with a male partner. She has not used illicit drugs or alcohol. Examination shows a grayish vaginal discharge with a pH greater than 4.5. A wet mount preparation of the vaginal discharge is most likely to show which of the following?

A
) Budding yeast

B
) Clue cells

C
) Ferning

D
) Leukocytes in sheets

E
) Trichomonas vaginalis

39. A 57-year-old woman with breast cancer comes to the physician because of increasing neck pain over the past 3 days. She has fallen frequently because of muscle weakness. Vital signs are within normal limits. Examination shows hyperreflexia of all extremities. There is tenderness over the cervical spine. Serum calcium level is 11 mg/dL. X-ray films show metastases to the cervical spine. Which of the following is the most appropriate next step in management?

A
) Application of a soft cervical collar

B
) Physical therapy

C
) Mithramycin therapy

D
) Tamoxifen therapy

E
) Spinal cord decompression and cervical stabilization

40. A 57-year-old man comes to the physician because of intermittent urinary incontinence over the past 6 months. He has loss of small amounts of urine when he coughs or sneezes. He has not had pain or blood with urination. He has a 15-year history of type 2 diabetes mellitus with peripheral neuropathy, retinopathy, and gastroparesis. Current medications include metoclopramide and glyburide. He appears well. Rectal examination shows a normal-sized prostate. Neurologic examination shows decreased sensation in a stocking-glove distribution. Achilles tendon reflexes are absent bilaterally. Test of the stool for occult blood is negative. Urinalysis shows 2+ protein with no leukocytes or erythrocytes. His postvoid residual volume is 500 mL. Which of the following is the most likely mechanism of this patient's incontinence?

A
) Central nervous system disorder

B
) Functional incontinence

C
) Intrinsic sphincter deficiency

D
) Overflow incontinence from acontractile bladder

E
) Overflow incontinence from bladder outlet obstruction

F
) Pelvic floor muscle weakness

G
) Retroperitoneal fibrosis

H
) Retroperitoneal lymphadenopathy

I
) Urinary tract infection

41. A 27-year-old primigravid woman at 38 weeks' gestation is admitted in labor. Her pregnancy has been uncomplicated, and a routine prenatal visit 2 days ago showed no abnormalities. On admission, fetal heart tones cannot be heard. Ultrasonography shows little amniotic fluid, fetal edema, and no evidence of a fetal heartbeat. After 1 hour, she delivers a 3175-g (7-lb) stillborn infant; examination of the infant shows no obvious abnormalities except for mild edema. The placenta and membranes appear normal. Which of the following is the most appropriate immediate course of action?

A
) Notify the hospital liability department

B
) Obtain consent for fetal organ donation from the parents

C
) Recommend autopsy of the infant

D
) Tell the mother not to worry since she can get pregnant again

E
) Tell the parents that there is a 1 in 4 chance of recurrence in future pregnancies

42. A previously healthy 16-year-old high school wrestler comes to the physician because of a rash on his forearms and the back of his legs for 1 week. He is allergic to pollen and dust. Examination shows patches of erythema with mild lichenification over the antecubital and popliteal fossae. There are clusters of painful umbilicated vesicles at sites of active skin inflammation. Which of the following is the most likely diagnosis?

A
) Eczema herpeticum

B
) Herpes zoster

C
) Keratosis pilaris

D
) Lichen planus

E
) Pityriasis rosea

43. A 5-week-old boy is brought to the physician because of vomiting for 3 days. Switching from a cow's milk-based formula to a soy-based formula and one bottle of an electrolyte solution has not decreased his vomiting. His mother says that there is no yellow color to the vomitus, but it is forceful and occurs immediately after he has had 1 to 2 ounces of liquid. He appears to vomit more liquid than he drank. He has one mustard-colored seedy stool daily. Examination shows no abnormalities. Which of the following is the most likely explanation for his vomiting?

A
) Duodenal atresia

B
) Gastroesophageal reflux

C
) Hypertrophic pyloric stenosis

D
) Lactose intolerance

E
) Protein malabsorption

F
) Rotavirus infection

44. A 28-year-old woman is hospitalized after taking a massive overdose of acetaminophen tablets in a suicide attempt. She has type 1 diabetes mellitus and major depressive disorder refractory to tricyclic antidepressant therapy. Despite appropriate therapy, she develops rapidly progressive hepatic failure and becomes progressively encephalopathic. On the 6th day of hospitalization, she is comatose. A CT scan of the brain shows mild diffuse swelling. An appropriately crossmatched, size-appropriate donor liver is available. Which of the following is the most appropriate course of action regarding transplantation?

A
) Do not proceed with the transplantation because diabetes mellitus is a contraindication

B
) Do not proceed with the transplantation because hepatic function is likely to return over the next week

C
) Do not proceed with the transplantation because major depressive disorder places the patient at risk for another suicide attempt

D
) Do not proceed with the transplantation because the onset of encephalopathy and CT findings suggest bacterial meningitis

E
) Proceed with the transplantation

45. A 3-year-old boy who is HIV positive is brought for a routine examination. His diet is appropriate for age. His medications include three antiretroviral drugs and trimethoprim-sulfamethoxazole for Pneumocystis carinii prophylaxis. Laboratory studies show:

Which of the following is most likely to have prevented this patient's anemia?

A
) Folic acid supplementation

B
) Iron supplementation

C
) Thyroid supplementation

D
) Vitamin B12 (cyanocobalamin) supplementation

E
) Monthly intravenous immune globulin therapy

46. A 20-year-old man is brought to the emergency department on a summer day 20 minutes after developing headache, nausea, and unsteady gait while running the last 2 miles of a marathon. On arrival, he is confused and disoriented. His temperature is 40 C (104 F), blood pressure is 100/60 mm Hg, and pulse is 155/min. His skin is warm and dry. Neurologic examination shows no focal findings. Which of the following is the most likely mechanism of this patient's condition?

1. A 77-year-old woman is brought to the physician by her son for a routine health maintenance examination. She says that she feels well. Her son reports that 1 month ago, she got lost while driving home from the local supermarket. Two weeks ago, she forgot to turn off the stove after cooking dinner. She has been wearing bilateral hearing aids since audiometry 2 years ago showed bilateral high-frequency hearing loss. Her visual acuity corrected with glasses is 20/25 in both eyes. Neurologic examination shows mild fine tremors of the hands when the arms are outstretched; the tremor is not present at rest. Muscle strength is 5/5 in all extremities. Deep tendon reflexes are decreased at the ankles and 2+ elsewhere. Her gait is normal. Sensation to vibration is mildly decreased over the toes. On mental status examination, she is awake, alert, and conversant. Her language function is normal. She is oriented to person, place, and time and recalls one out of three objects after 10 minutes. Which of the following findings in this patient warrants further evaluation?

A
) Decreased deep tendon reflexes at the ankles

B
) Decreased sensation to vibration over the toes

C
) High-frequency hearing loss

D
) Memory loss

E
) Tremor of the outstretched hands

2. A 10-year-old girl is brought to the emergency department because of diffuse, aching abdominal pain, nausea, and recurrent vomiting over the past 5 hours. She has an 8-year history of type 1 diabetes mellitus treated with 20 U of NPH and 6 U of regular insulin in the morning and 14 U of NPH and 5 U of regular insulin in the evening. She appears lethargic but is easily arousable. There is an obvious odor of ketones on her breath. Her blood pressure is 100/70 mm Hg, pulse is 95/min, and respirations are 20/min and deep. Serum studies show:

Na+ 142 mEq/L
K+ 5.3 mEq/L
HCO3– 6 mEq/L
Glucose 710 mg/dL

Which of the following laboratory findings is most likely to be increased?

A ) Arterial pH

B ) Serum C-peptide level

C ) Serum magnesium level

D ) Serum osmolality

E ) Serum phosphorus level

3. A healthy 24-year-old woman comes for a routine health maintenance examination. Menses occur at regular 28-day intervals and last 5 to 6 days. Her last menstrual period was 3 weeks ago. She takes no medications. Bimanual examination shows a 5-cm, mildly tender left adnexa. A pregnancy test is negative. Which of the following is the most appropriate next step in management?

A
) Repeat examination in 2 weeks

B
) Measurement of serum CA 125 level

C
) Measurement of serum α-fetoprotein level

D
) CT scan of the pelvis

E
) Diagnostic laparoscopy

4. A 24-year-old primigravid woman at 18 weeks' gestation comes for a routine prenatal visit. She has had increased bowel movements over the past 9 weeks; the stools are sometimes covered with mucus and blood. Use of over-the-counter antidiarrheal drugs has not relieved her symptoms. Pregnancy has been otherwise uncomplicated. She has never traveled outside the USA. Examination shows erythematous, tender nodules over the anterior surface of both lower extremities; some of the nodules have a violaceous hue. The uterus is consistent in size with an 18-week gestation. Rectal examination shows no hemorrhoids or fissures. Fetal heart tones are audible by Doppler. Which of the following is the most likely diagnosis?

A
) Amebiasis

B
) Diverticulitis

C
) Hyperperistaltic diarrhea

D
) Inflammatory bowel disease

E
) Viral gastroenteritis

5. A 32-year-old woman at 38 weeks' gestation comes for a routine prenatal visit. During routine screening at 28 weeks' gestation, she tested positive for hepatitis B surface antigen. Her pregnancy has been otherwise uncomplicated. Examination shows a uterus consistent in size with a 38-week gestation. Which of the following measures is most likely to decrease the risk for hepatitis B infection in her newborn?

A
) Recommendation of bottle-feeding rather than breast-feeding

B
) Maternal administration of hepatitis B immune globulin (HBIG) now

C
) Neonatal administration of HBIG after delivery and hepatitis B vaccine at 3 months of age

6. A 37-year-old woman comes to the physician because of progressive shortness of breath over the past 5 years; she now has fatigue and shortness of breath with mild exertion. She has a history of mitral stenosis secondary to rheumatic fever at the age of 15 years. She was asymptomatic until 5 years ago when she developed severe shortness of breath during pregnancy. She was treated with diuretics, low-sodium diet, and bed rest, and she was able to deliver the baby at term. Her only medication is hydrochlorothiazide. Her temperature is 37 C (98.6 F), blood pressure is 110/80 mm Hg, pulse is 100/min and regular, and respirations are 26/min. Cardiac examination shows an obvious opening snap in S2. A grade 3/6, late diastolic murmur is heard at the apex. A right ventricular lift is palpated along the left sternal border. Which of the following is most likely increased in this patient?

A
) Blood flow to the lower lung fields

B
) Diastolic filling time

C
) Left-to-right shunt of blood

D
) Left ventricular end-diastolic pressure

E
) Pulmonary artery pressure

7. A 5-year-old girl with ventricular septal defect is scheduled for tonsillectomy in 2 weeks. She has no known drug allergies. Her temperature is 37 C (98.6 F). Examination shows no abnormalities. Which of the following is the most appropriate prophylaxis prior to tonsillectomy?

A
) Amoxicillin

B
) Ciprofloxacin

C
) Rifampin

D
) Tetracycline

E
) Trimethoprim-sulfamethoxazole

F
) No prophylaxis indicated

8. An 8-year-old girl with type 1 diabetes mellitus is brought to the emergency department 10 minutes after being involved in a motor vehicle collision. She was in the back seat of a small automobile that was rear-ended. Initially, she was alert during transport and reported bilateral thigh pain, but then she stopped talking, closed her eyes, and became unresponsive to voice; on arrival, she responds to noxious stimuli with brief grimaces and no withdrawal. Her blood pressure is 40/palpable mm Hg, pulse is 148/min, and respirations are 28/min. Air entry is symmetric. The pupils are equal and react to light. No cardiac murmur is heard. The abdomen is soft. There is swelling of the upper portions of both thighs. Her hematocrit is 37%. Which of the following is the most appropriate next step in management?

A
) Measurement of arterial blood gases

B
) X-ray film of the chest

C
) CT scan of the head

D
) Administration of 50% dextrose in water

E
) Infusion of 0.9% saline

9. A previously healthy 16-year-old boy is brought to the emergency department 20 minutes after an episode of left arm shaking that lasted approximately 3 minutes. Over the past 2 days, he has had fever and emotional lability. On arrival, his temperature is 38.9 C (102 F). He is somnolent and disoriented to person, place, and time. He responds poorly to pain. Neurologic examination shows no other abnormalities. Laboratory studies show:

Which of the following is the most likely cause of this patient's neurologic findings?

A
) Bacterial infection

B
) Congenital malformation

C
) Fungal infection

D
) Hemorrhage

E
) Immune-mediated demyelination

F
) Parasitic infection

G
) Viral infection

10. A 72-year-old man with hypertension has had increasingly severe back pain over the past 2 months. He had a myocardial infarction 4 years ago. He has marked tenderness over T11, T12, L1, and L2. An x-ray film of the lumbosacral spine shows osteoblastic lesions in these vertebrae. Which of the following is the most likely diagnosis?

A
) Abdominal aneurysm

B
) Fibrosarcoma

C
) Metastatic prostate carcinoma

D
) Multiple myeloma

E
) Osteosarcoma

11. A 64-year-old woman has moderately severe postoperative pain 1 day after a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Which of the following is the most appropriate analgesic pharmacotherapy?

A
) Oral aspirin-codeine compound

B
) Oral diazepam

C
) Oral ibuprofen

D
) Intermittent intravenous naloxone

E
) Patient-controlled intravenous morphine

F
) Transcutaneous administration of fentanyl

12. A 37-year-old woman comes to the physician because of a 1-day history of throbbing facial pain. She describes the pain as 7 out of 10 in intensity. Over the past 9 days, she has had nasal congestion, purulent nasal discharge, sore throat, and a nonproductive cough. She does not smoke. Her husband and children have had no recent illness. Her temperature is 38.5 C (101.3 F). Examination shows congested nasal mucosa and purulent discharge on the left. There is tenderness to palpation over the left cheek and no transillumination over the left maxillary sinus. The tympanic membranes are normal, and there is no erythema of the throat. Examination shows no cervical adenopathy. The lungs are clear to auscultation. Which of the following is the most likely causal organism?

A
) Haemophilus influenzae type b

B
) Moraxella catarrhalis

C
) Staphylococcus aureus

D
) Streptococcus pneumoniae

E
) Streptococcus pyogenes (group A)

13. A 42-year-old woman comes to the physician for an annual pelvic examination and Pap smear. Over the past year, she has had increasing fatigue and difficulty sleeping. She has two children who both attend college. She is currently looking for part-time work outside the home. Her husband has been busy in a new start-up business. Examination shows no abnormalities. Laboratory studies show:

Which of the following is the most likely explanation for this patient's laboratory abnormalities?

A
) Acetaminophen

B
) Alcohol

C
) Diphenhydramine

D
) Estrogen effect

E
) Ibuprofen

14. Five weeks after vaginal delivery of a healthy full-term newborn, a 22-year-old woman, gravida 1, para 1, is brought to the physician by her mother because of depressed mood for 2 weeks. Her mother is concerned that her daughter is not able to take care of her infant. Physical examination shows no abnormalities. She is quiet and tearful and does not engage in conversation easily. She states that she lives alone with her infant and has had thoughts of suicide and infanticide. Which of the following is the most appropriate next step in management?

A
) Reassurance

B
) Long-term outpatient counseling

C
) Antipsychotic therapy

D
) Selective serotonin reuptake inhibitor therapy

E
) Admission to the hospital for treatment

15. A 72-year-old man comes for a routine follow-up examination. He has chronic obstructive pulmonary disease treated with β-adrenergic agonists and ipratropium by metered-dose inhaler and mild arterial insufficiency of the lower extremities treated with aspirin. His blood pressure is 160/60 mm Hg, pulse is 70/min, and respirations are 12/min. Funduscopic examination shows arteriovenous nicking. Pedal pulses are decreased bilaterally. Which of the following antihypertensive drugs is most likely to cause adverse effects in this patient?

A
) α2-Adrenergic agonist

B
) α-Adrenergic blocking agent

C
) β-Adrenergic blocking agent

D
) Angiotensin-converting enzyme (ACE) inhibitor

E
) Calcium-channel blocking agent

F
) Loop diuretic

G
) Thiazide diuretic

H
) Vasodilator

The response options for the next two items are the same. You will be required to select one answer for each item in the set.

For each patient with loss of consciousness, select the most likely diagnosis.

A
) Aortic stenosis

B
) Carotid sinus hypersensitivity

C
) Conversion reaction

D
) Hypertrophic obstructive cardiomyopathy

E
) Hypoglycemia

F
) Mitral valve prolapse

G
) Orthostatic hypotension

H
) Pulmonary embolus

I
) Seizure

J
) Vasovagal syncope

K
) Vertebrobasilar insufficiency

16. A 15-year-old boy is brought to the emergency department 30 minutes after a 2-minute episode of loss of consciousness after completing a 400-meter race. On awakening, he says that he feels fine except for shortness of breath. He weighs 82 kg (180 lb) and is 191 cm (75 in) tall. His blood pressure is 110/70 mm Hg, pulse is 70/min and regular, and respirations are 15/min. The lungs are clear to auscultation. A grade 2/6 systolic murmur is heard at the left sternal border with minimal radiation to the neck; the murmur becomes louder when he stands.

For each patient with loss of consciousness, select the most likely diagnosis.

A
) Aortic stenosis

B
) Carotid sinus hypersensitivity

C
) Conversion reaction

D
) Hypertrophic obstructive cardiomyopathy

E
) Hypoglycemia

F
) Mitral valve prolapse

G
) Orthostatic hypotension

H
) Pulmonary embolus

I
) Seizure

J
) Vasovagal syncope

K
) Vertebrobasilar insufficiency

17. A 62-year-old woman is brought to the emergency department 1 hour after a 1-minute episode of loss of consciousness; her symptoms began when she stood up after she passed a dark, watery stool. She has had diarrhea and dark stools for 2 days. She has been receiving warfarin therapy for deep venous thrombosis for 2 weeks. On arrival, her blood pressure is 82/60 mm Hg, and pulse is 150/min and regular. She is unable to stand. The lungs are clear to auscultation. A grade 2/6 systolic murmur is heard at the second right intercostal space with no radiation. Examination shows a soft, nontender abdomen. There is 1+ edema of the right lower extremity with no tenderness. Test of the stool for occult blood is positive.

18. A 50-year-old woman has had progressive dyspnea over the past 2 weeks and constant, sharp chest pain for 4 days. The pain is localized to the center of the chest and is worse while supine. She underwent a right, modified radical mastectomy and adjuvant chemotherapy for breast cancer 3 years ago. She has a history of hypothyroidism treated with thyroid replacement therapy. She has smoked one pack of cigarettes daily for 30 years and drinks two ounces of alcohol daily. She is dyspneic and diaphoretic. Her temperature is 37.2 C (99 F), blood pressure is 90/70 mm Hg with a pulsus paradoxus of 20 mm Hg, pulse is 110/min, and respirations are 28/min. Examination shows jugular venous distention to the angle of the mandible. The liver span is 14 cm with 4 cm of shifting abdominal dullness. Arterial blood gas analysis on room air shows a pH of 7.50, PCO2 of 30 mm Hg, and PO2 of 70 mm Hg. An x-ray film of the chest shows an enlarged cardiac silhouette with a globular configuration. An ECG shows sinus tachycardia with nonspecific ST-segment changes diffusely. Which of the following is the most appropriate next step in management?

A ) Echocardiography

B ) CT scan of the abdomen

C ) Ventilation-perfusion lung scans

D ) Bronchoscopy

E ) Paracentesis

19. A 3-year-old boy is brought to the physician because of a 7-day history of fever and a painful swollen lymph node in his groin. This is his sixth episode of lymph node swelling; the previous episodes resolved after drainage and prolonged antibiotic therapy. He also had pneumonia at the age of 12 months that required chest tube placement for drainage. A maternal uncle died during childhood of recurrent infections. The patient is at the 5th percentile for height and weight. His temperature is 38.5 C (101.3 F). Examination shows a warm, tender, erythematous lymph node in the right inguinal area. There are several healed incisions over the inguinal area and neck from old drainage sites. Laboratory studies show:

A Gram's stain of the lymph node aspirate shows numerous segmented neutrophils filled with bacteria; cultures grow Staphylococcus aureus. Which of the following is the most likely mechanism for these findings?

A
) Adenosine deaminase deficiency

B
) Consumption of complement

C
) Defective opsonization

D
) Destruction of CD4+ T lymphocytes

E
) Developmental arrest of maturation of B lymphocytes

F
) Dysmorphogenesis of the third and fourth pharyngeal pouches

G
) Impaired chemotaxis

H
) Impaired phagocytic oxidative metabolism

20. A 67-year-old woman has been intubated for 1 week after undergoing a left lobectomy for lung cancer. She has chronic obstructive pulmonary disease. Her preoperative functional vital capacity was 40% of predicted. She is awake and alert. Her blood pressure is 130/75 mm Hg, and pulse is 72/min. The ventilator settings are a synchronized intermittent mandatory ventilation of 8/min, FIO2 of 40%, and positive-end expiratory pressure of 5 cm H2O. Arterial blood gas analysis shows:

pH 7.42
PCO2 47 mm Hg
PO2 90 mm Hg
O2 saturation 96%

Which of the following is the most appropriate next step in management?

A
) Antibiotic therapy

B
) Bronchodilator therapy

C
) Chest physiotherapy

D
) Decrease inotropes

E
) Diuretic therapy

F
) Fiberoptic bronchoscopy

G
) Heparin therapy

H
) Incentive spirometry

I
) Increase FIO2

J
) Increase inotropes

K
) Increase respiratory rate

L
) Placement of thoracostomy tube

M
) Tracheostomy

N
) Wean from the ventilator

21. A 67-year-old woman is brought to the emergency department because of severe chest pain 4 hours after undergoing outpatient endoscopy and dilatation of an esophageal stricture caused by reflux. At discharge, she reported no chest pain. Three hours later, she vomited a small amount of blood and had severe pain. She is pale. Her temperature is 38 C (100.4 F), blood pressure is 140/85 mm Hg, pulse is 125/min, and respirations are 22/min. Examination shows crepitus in the neck and moderate epigastric tenderness. The lungs are clear to auscultation, and breath sounds are equal bilaterally. Rectal examination shows no masses; test of the stool for occult blood is positive. Which of the following is the most likely cause of these symptoms?

A
) Bleeding from erosive esophagitis

B
) Esophageal perforation

C
) Mallory-Weiss syndrome

D
) Myocardial infarction

E
) Perforated gastric ulcer

22. An 87-year-old woman is brought to the physician by her son because of progressive memory loss over the past 2 years. Her son says that she repeats herself frequently and has been forgetting to take her routine medications. She takes hydrochlorothiazide for mild systolic hypertension and levothyroxine for hypothyroidism. She had vulvar cancer 10 years ago treated with wide excision. Her blood pressure is 138/78 mm Hg. Physical examination is within normal limits for her age. Mini-Mental State Examination score is 23/30. Laboratory studies, including serum vitamin B12 (cyanocobalamin), thyroxine (T4), and thyroid-stimulating hormone levels, are within normal limits. A CT scan of the head shows mild volume loss. Which of the following is the most appropriate pharmacotherapy?

A
) β-Adrenergic agonist

B
) Cholinesterase inhibitor

C
) Dopamine agonist

D
) Prednisone

E
) Selective serotonin reuptake inhibitor

23.

A newborn is in severe respiratory distress immediately following delivery. She was born at 35 weeks' gestation to a 35-year-old woman, gravida 2, para 1, aborta 1, who did not receive prenatal care. The newborn's pulse is 60/min, and respirations are irregular and labored. Examination shows pallor with perioral cyanosis, anasarca, hepatosplenomegaly, and scattered petechiae. Cord blood hemoglobin is 4 g/dL, and reticulocyte count is 18%. A direct antiglobulin (Coombs') test is positive. Which of the following sets of blood groups is most likely in the mother and her newborn?

Mother Newborn

A
)
A, Rh-positive O, Rh-positive

B
)
A, Rh-positive O, Rh-negative

C
)
A, Rh-negative O, Rh-negative

D
)
O, Rh-positive O, Rh-negative

E
)
O, Rh-negative O, Rh-positive

24. After an uncomplicated laparoscopic cholecystectomy, a 62-year-old man has not had any urine output since the Foley catheter was removed 12 hours ago. During the hour before the operation, the 40 minutes of operating room time, and the 2 hours in the recovery room, his fluid input was 2.5 L and urine output was 1 L. Since that time, he has been receiving intravenous 5% dextrose in water with 0.45% saline and morphine. He is awake and alert and has a moderate amount of abdominal pain. Preoperative serum studies showed:

One hour after receiving an intravenous bolus of 0.9% saline, the patient does not produce any urine. Which of the following is the most appropriate next step in management?

A
) Increase in the dose of morphine

B
) Intravenous administration of an additional bolus of 0.9% saline

C
) Intravenous administration of doxazosin

D
) Intravenous administration of furosemide

E
) Reinsertion of a Foley catheter

25. A healthy 55-year-old man comes for an initial health maintenance examination. His last visit to a physician was over 10 years ago. He does not smoke and drinks only on social occasions. Examination shows no abnormalities. Which of the following immunizations should be administered?

A
) Hepatitis A vaccine

B
) Influenza virus vaccine

C
) Measles-mumps-rubella vaccine

D
) Pneumococcal vaccine

E
) Diphtheria-tetanus toxoid

26. A 19-year-old man comes to the physician because of frequent nosebleeds over the past 3 weeks. He has bipolar disorder currently well controlled with lithium carbonate, bupropion, and valproic acid. Physical examination shows no abnormalities except for dried blood in the nares. Mental status examination shows an anxious mood and slight motor restlessness. Serum studies show a lithium carbonate level of 1.3 mEq/L (therapeutic range=0.6–1.2), and valproic acid level of 77 μg/mL (therapeutic range=40–100). Which of the following is the most appropriate next step in management?

27. An asymptomatic 32-year-old man comes for a routine health maintenance examination. He has a 10-year history of frequent sinus and pulmonary infections. He had an anaphylactic reaction to a blood transfusion following a motor vehicle collision 3 years ago. His temperature is 37 C (98.6 F). Examination shows mild erythema in the posterior pharynx. The lungs are clear to auscultation. A complete blood count and serum protein electrophoresis are within normal limits. Which of the following is the most likely cause of the frequent infections?

A
) Colonization with Streptococcus pneumoniae

B
) Common variable immunodeficiency

C
) HIV infection

D
) Selective IgA deficiency

E
) X-linked agammaglobulinemia

28.

A 37-year-old man is brought to the emergency department 6 hours after the onset of constant, increasingly severe abdominal pain and nausea. His symptoms awoke him from sleep, and he has vomited once since that time. He has no history of similar symptoms, and he does not take any medications or use alcohol or illicit drugs. Family history is noncontributory. He is in acute distress and lying in the fetal position. Any movement exacerbates the pain. His temperature is 37.8 C (100 F), blood pressure is 108/68 mm Hg, pulse is 112/min, and respirations are 24/min. The lungs are clear to percussion and auscultation. Examination shows a rigid abdomen; bowel sounds are absent. Laboratory studies show:

An x-ray film of the chest shows a small amount of free air under the left diaphragm. Administration of antibiotics and fluids is begun. Which of the following is the most appropriate next step in management?

A
) Barium swallow

B
) CT scan of the abdomen

C
) Intravenous administration of an H2-receptor blocking agent

D
) Upper endoscopy

E
) Laparotomy

29. A 52-year-old woman with alcoholism comes to the physician after a serum cholesterol level of 290 mg/dL was found on a routine screening. She drinks a pint of vodka daily. She takes captopril for hypertension and glyburide for type 2 diabetes mellitus. She also has intermittent episodes of gout. Fasting serum studies show:

Which of the following is the most appropriate next step in management?

A
) Alcohol cessation

B
) Better control of diabetes

C
) Switch from captopril to calcium-channel blocking agent therapy

D
) Gemfibrozil therapy

E
) Thyroid replacement therapy

30. A 23-year-old woman has pain, cramping, and swelling of the right calf 3 days after an uncomplicated labor and delivery. The right foot is swollen, and there is marked tenderness with dorsiflexion and palpation of the right calf. Examination shows no other abnormalities. A complete blood count and serum electrolyte levels are within normal limits. Which of the following is the most likely cause of this condition?

A
) Hypercoagulable state of pregnancy

B
) Hyperuricemia

C
) Peripheral artery aneurysm

D
) Platelet embolus

E
) Prolonged pressure on the vena cava during delivery

31. A 2-month-old boy is brought to the physician for a well-child examination. He smiles spontaneously and vocalizes without crying, but he does not appear to laugh or squeal. He will not work for a toy that is out of his reach. Which of the following is the most appropriate assessment of language and psychosocial development?

Language
Psychosocial
development
development

A
)
Normal
normal

B
)
Normal
delayed

C
)
Delayed
normal

D
)
Delayed
delayed

32. A previously healthy 24-year-old woman comes to the physician because of a low-grade fever and a nonproductive cough for 7 days. She has been able to continue her daily activities. Her temperature is 37.7 C (99.9 F). A few scattered inspiratory crackles are heard in the thorax. An x-ray film of the chest shows patchy infiltrates in both lungs. Which of the following is the most appropriate initial pharmacotherapy?

A
) Amoxicillin

B
) Cefaclor

C
) Ciprofloxacin

D
) Erythromycin

E
) Trimethoprim-sulfamethoxazole

33. A 45-year-old woman comes to the emergency department because of shortness of breath, chest pain, dizziness, and mild numbness and tingling around the lips for 2 hours. She says that she feels like she is going to die. She had three similar episodes last week when she was vacationing at the Grand Canyon; the first episode occurred while crossing a narrow bridge on a donkey. She takes a hypoglycemic drug for type 2 diabetes mellitus, verapamil for hypertension, and sumatriptan as needed for migraine. She is mildly diaphoretic and appears pale. Her blood pressure is 130/90 mm Hg, pulse is 120/min, and respirations are 28/min. Serum glucose level is 120 mg/dL. An ECG shows sinus tachycardia. Sublingual nitroglycerin therapy does not relieve her symptoms and gives her a headache. The most appropriate next step in management is administration of which of the following?

A
) Haloperidol

B
) Lorazepam

C
) Oxygen

D
) Sumatriptan

E
) Verapamil

34. A 67-year-old man is brought to the emergency department 4 hours after the onset of severe midlumbar back pain. He is anxious, pale, and diaphoretic. His temperature is 37.1 C (98.8 F), blood pressure is 105/65 mm Hg, and pulse is 120/min. Examination shows no other abnormalities. X-ray films of the lumbar spine show degenerative disc disease with calcifications anterior to the vertebral bodies. Which of the following is the most likely diagnosis?

A
) Aortoiliac occlusion

B
) Herniated nucleus pulposus

C
) Lumbar discitis

D
) Lumbar strain

E
) Pyelonephritis

F
) Ruptured aortic aneurysm

G
) Spinal stenosis

35. A 17-year-old boy is brought to the emergency department by his parents because of bizarre behavior for 6 hours. Last night he was out with friends, and since returning, he has been confused and has "trashed" his room. His blood pressure is 165/95 mm Hg. He is hypervigilant, has little spontaneous speech, and is disoriented to place and time. He appears catatonic but abruptly becomes assaultive two times and needs to be restrained. Which of the following is the most likely substance taken?

A
) Cocaine

B
) Ecstasy

C
) LSD

D
) Methaqualone

E
) PCP

The response options for the next two items are the same. You will be required to select one answer for each item in the set.

For each patient with back pain, select the most likely diagnosis.

A
) Herniated disc

B
) Lumbar spinal stenosis

C
) Metastatic cancer

D
) Muscle strain

E
) Osteoporotic compression fracture

F
) Sacroiliitis

G
) Spinal epidural abscess

H
) Spondylolisthesis

36. A 57-year-old woman is brought to the physician 2 days after the sudden onset of severe low back pain; the pain does not radiate to the lower extremities. The pain began when she was lifting her grandson. She does not have weakness or sensory loss in the legs and has had no urinary incontinence. She has a 10-year history of rheumatoid arthritis treated with prednisone. Her temperature is 37 C (98.6 F), blood pressure is 130/60 mm Hg, and pulse is 64/min. Examination shows deformities of the interphalangeal joints of the hands and exquisite tenderness to percussion over the lumbar spine. Bilateral straight-leg raising to 80 degrees does not increase the pain. Muscle strength and sensation are intact in the lower extremities. Deep tendon reflexes are 2+ bilaterally. Babinski's sign is absent bilaterally.

For each patient with back pain, select the most likely diagnosis.

A
) Herniated disc

B
) Lumbar spinal stenosis

C
) Metastatic cancer

D
) Muscle strain

E
) Osteoporotic compression fracture

F
) Sacroiliitis

G
) Spinal epidural abscess

H
) Spondylolisthesis

37. A previously healthy 32-year-old plumber comes to the physician because of a 3-week history of constant, dull, low back pain that does not radiate to the extremities. The pain began after he unloaded heavy equipment from his van. It increases with activity and is temporarily relieved by bed rest and ibuprofen. Examination shows tenderness to palpation over the lumbar paraspinal region bilaterally. The pain increases with forward or lateral movements of the spine. Muscle strength and sensation are intact in the lower extremities. Bilateral straight-leg raising to 80 degrees does not increase the pain. Deep tendon reflexes are 2+ bilaterally. Babinski's sign is absent bilaterally.

38. A 72-year-old man comes to the physician because of a 2-month history of urination twice nightly and occasional urinary frequency and urgency. He has a 15-year history of type 2 diabetes mellitus now moderately well controlled with glyburide. His father was diagnosed with prostate cancer at the age of 70 years, and his sister died of complications from systemic lupus erythematosus. His blood pressure is 135/86 mm Hg. Cardiopulmonary examination shows no abnormalities. Abdominal examination shows no suprapubic fullness or tenderness. There is mild enlargement of the prostate with no palpable nodules. His postvoid residual volume is 10 mL. Serum studies show a urea nitrogen (BUN) level of 45 mg/dL and creatinine level of 3.8 mg/dL. Urine dipstick shows 3+ protein. Which of the following is most likely to have prevented progression of this patient's renal disease?

A
) Intermittent Foley catheterization

B
) Intravenous mannitol therapy

C
) Oral cyclophosphamide and prednisone therapy

D
) Oral enalapril therapy

E
) Oral finasteride therapy

F
) Oral prednisone therapy only

G
) Oral terazosin therapy

39. Two hours ago, a 24-year-old man had the sudden onset of pain in the right side of his chest that has become increasingly severe. He is now having difficulty breathing. His temperature, blood pressure, and pulse are normal. An x-ray film of the chest is shown. Which of the following is the most appropriate next step in management?

A
) Bed rest and sedative therapy

B
) Antibiotic therapy

C
) Anticoagulant therapy

D
) Tube thoracostomy

E
) Immediate thoracotomy

40. A 21-year-old college student comes to the physician because of acne that developed 4 days ago while she was taking her medical college admission test. She is concerned about her appearance and plans to be in a wedding in 3 weeks. She has had similar episodes that have resolved completely without treatment. Examination shows acute acne over the face with a predominance of comedones and pustules. There is no evidence of chronic scarring. Which of the following is the most appropriate initial step in treatment?

A
) Dietary restriction of chocolates and simple sugars

B
) Dietary restriction of milk products

C
) Topical acyclovir

D
) Topical hydrocortisone cream

E
) Topical retinoic acid

41. A 67-year-old woman comes for a routine health maintenance examination. She exercises regularly. She is not sexually active. At her last visit 1 year ago, her serum cholesterol level was 180 mg/dL, and fasting serum glucose level was 80 mg/dL; a Pap smear and mammography showed normal findings. Two years ago, flexible sigmoidoscopy showed no abnormalities. Today, she weighs 63 kg (140 lb) and is 165 cm (65 in) tall. Her blood pressure is 120/80 mm Hg. Examination shows no abnormalities. Which of the following is the most appropriate screening test for this patient?

A
) Pap smear

B
) Measurement of serum cholesterol level

C
) Measurement of serum glucose level

D
) Mammography

E
) Flexible sigmoidoscopy

42. A 62-year-old man has had the gradual onset of fatigue and shortness of breath over the past 3 years. There is striking jugular venous distention with a large wave occurring with S2. The carotid upstroke is normal. Cardiac examination shows a lifting systolic motion of the sternum and no palpable point of maximal impulse. A grade 3/6, holosystolic, plateau-shaped murmur that is loudest on inspiration is heard at the lower left sternal border. The liver is enlarged and tender, and the abdomen is swollen with a fluid wave. There is marked ankle edema. Which of the following is the most likely cause of the murmur?

A
) Aortic stenosis

B
) Mitral regurgitation

C
) Mitral stenosis

D
) Tricuspid regurgitation

E
) Ventricular septal defect

43. A 24-year-old woman comes to the physician because of constant, severe pain in her neck, shoulders, and back for 3 months. She has been unable to enjoy her usual activities because of the pain. Use of over-the-counter ibuprofen and aspirin has not relieved her symptoms. She has a history of irritable bowel syndrome. Examination shows multiple tender spots over the neck, shoulders, and lumbar spine. Range of motion of all joints is full. There is no evidence of synovitis. Fluorescent serum antinuclear antibody and rheumatoid factor assays are negative. Which of the following is the most likely diagnosis?

A
) Ankylosing spondylitis

B
) Fibromyalgia

C
) Polymyalgia rheumatica

D
) Polymyositis

E
) Seronegative rheumatoid arthritis

44. A 72-year-old man comes to the physician because of a 6-month history of mild to moderate shortness of breath when climbing stairs. He had a myocardial infarction 2 years ago and has had an ejection fraction of 35% since then. His only medication is a β-adrenergic blocking agent. The lungs are clear to auscultation. Cardiac examination shows an S4 gallop. There is no peripheral edema. Laboratory studies are within normal limits. An ECG shows no acute changes. Which of the following is the most appropriate pharmacotherapy?

A
) α-Adrenergic blocking agent

B
) Angiotensin-converting enzyme (ACE) inhibitor

C
) Angiotensin2-receptor blocking agent

D
) Nitrates

E
) Thiazide diuretic

45. A 42-year-old woman comes to the physician because of a 3-month history of a recurrent vivid dream that several men are assaulting her and her children. Upon awakening, she is anxious and distressed by the frightening images. She realizes that it is just a dream but is afraid to go back to sleep. She does not know why she is having this particular dream because she has never been the victim of an assault. She drinks two to three cups of coffee each morning. She does not use illicit drugs. Physical examination shows no abnormalities. There is no evidence of depressed mood or hallucinations. Laboratory studies are within normal limits. Which of the following is the most likely diagnosis?

A
) Acute stress disorder

B
) Nightmare disorder

C
) Panic disorder

D
) Sleep apnea

E
) Sleep terror disorder

46. A 57-year-old man is brought to the emergency department 30 minutes after he was found on the floor of his house; he has left hip pain and shortness of breath. He has renal failure but has missed his last two dialysis treatments. His renal failure was caused by inadvertent ingestion of ethylene glycol. His renal function did not improve, and he is currently on the transplantation list. Medications include amlodipine and doxazosin. On arrival, his temperature is 37.5 C (99.5 F), blood pressure is 150/100 mm Hg, pulse is 95/min and regular, and respirations are 24/min. His breathing is rapid and deep. Crackles are heard in the lung bases. Examination shows a soft abdomen. Bowel sounds are normal. The left lower extremity is externally rotated. Laboratory studies show:

Serum
Na+ 135 mEq/L
Cl– 102 mEq/L
K+ 7.1 mEq/L
HCO3– 12 mEq/L

Arterial blood gas analysis on 4 L/min of oxygen by nasal cannula:

pH 7.22
PCO2 31 mm Hg
PO2 61 mm Hg

An ECG shows peaked T-waves. It will be at least 45 minutes before dialysis can be started. Which of the following is the most appropriate next step in management?

1. A 26-year-old woman is brought to the emergency department because of marked confusion for 2 hours; she also has had a flu-like illness for 3 days. Over the past 6 weeks, she has had increased fatigue, weakness, and nausea. She recently started thyroid hormone replacement therapy for autoimmune thyroiditis; 1 week ago, her serum thyroid-stimulating hormone level was 3 μU/mL. Her temperature is 38 C (100.4 F), blood pressure is 80/40 mm Hg, and pulse is 140/min. She appears confused and lethargic. Examination shows cool, mottled skin. There is generalized hyperpigmentation, especially involving the palmar creases. The lungs are clear to auscultation. Abdominal examination shows diffuse mild tenderness and no rebound. Laboratory studies show:

An x-ray film of the chest and urinalysis show normal findings. An ECG shows sinus tachycardia with peaked T waves. Which of the following is most likely to confirm the primary cause of this patient's condition?

A
) Measurement of pulmonary artery pressure

B
) Measurement of right atrial pressure

C
) Measurement of serum antithyroglobulin antibody level

D
) Measurement of serum lactate dehydrogenase activity

E
) Measurement of serum thyroid-stimulating hormone level

F
) ACTH stimulation test

G
) Dexamethasone suppression test

H
) Blood cultures

I
) Echocardiography

2. A 27-year-old man comes to the physician because of a 1-week history of shortness of breath with exertion, paroxysmal nocturnal dyspnea, and swelling of his feet. He has not had chest pain or palpitations. He has been healthy except for a "bad cold" 1 month ago that resolved spontaneously after 10 days. His temperature is 37 C (98.6 F), blood pressure is 90/60 mm Hg, pulse is 120/min, and respirations are 24/min. Examination shows jugular venous distention to 8 cm. Bilateral basilar crackles are heard. Cardiac examination shows a diffuse, laterally displaced point of maximal impulse. There is a normal S1 and S2 and an S3. Examination shows 2+ pretibial edema bilaterally. An ECG shows no abnormalities. Echocardiography is most likely to show which of the following?

A
) Asymmetric septal hypertrophy

B
) Bicuspid aortic valve with stenosis

C
) Diffuse hypokinesia and dilation of the ventricles

D
) Dyskinesia of the left ventricular apex

E
) Mitral valve prolapse

3.

A 35-year-old man is brought to the emergency department because of intractable nausea and vomiting of nonbilious fluid over the past 48 hours. He has a history of duodenal ulcer disease treated with H2-receptor blocking agents. His temperature is 37 C (98.6 F), blood pressure is 90/60 mm Hg, pulse is 130/min, and respirations are 10/min. Examination shows mild epigastric tenderness. Which of the following are the most likely serum electrolyte findings?

Na+ Cl– K+ HCO3–
(mEq/L) (mEq/L) (mEq/L) (mEq/L)

A
)
115 80 4.0 25

B
)
140 80 2.5 40

C
)
145 100 5.0 15

D
)
150 105 2.5 25

E
)
160 135 5.0 25

4. A 3-year-old boy is brought for a follow-up examination. He just completed a 10-day course of amoxicillin that has not resolved his right ear pain. He appears irritable. His temperature is 38.9 C (102 F). Examination shows downward and lateral displacement of the right auricle with tenderness to palpation of the posterior auricular area; his neck is supple. Which of the following is the most appropriate next step in diagnosis?

A
) Bone scan

B
) CT scan of the head

C
) Tympanometry

D
) Lumbar puncture

E
) Tympanocentesis

5. A 67-year-old man has had shortness of breath on exertion for 3 months; he has had an 11.3-kg (25-lb) weight loss during this period. He has smoked two packs of cigarettes daily for 25 years. He appears chronically ill. Examination shows decreased breath sounds on the left; heart sounds are normal. An x-ray film of the chest shows a large left-sided pleural effusion. Which of the following is the most appropriate next step in diagnosis?

A
) Bronchoscopy

B
) Thoracoscopy

C
) Closed pleural biopsy

D
) Open pleural biopsy

E
) Thoracentesis

6. A program for the primary prevention of coronary artery disease is implemented in a community in the USA. Assuming that diagnostic procedures and detection remain the same, which of the following measures involving the disease is most effective in monitoring the program?

A
) Case fatality

B
) Hospitalization

C
) Incidence

D
) Mortality

E
) Prevalence

7. A 77-year-old woman comes to the physician because of low back pain for 3 months. She has hypertension controlled with a calcium-channel blocking agent and type 2 diabetes mellitus controlled with diet. Her vital signs are within normal limits. Examination shows no spinal or costovertebral angle tenderness; straight-leg raising produces pain in the low back at the L2–4 range. Knee jerk and ankle reflexes are 2+ bilaterally. Babinski's sign is absent bilaterally. Urinalysis shows 5–10 epithelial cells/hpf, 2–5 leukocytes/hpf, and few bacteria. Which of the following is the most appropriate pharmacotherapy?

A
) Acetaminophen

B
) Gold

C
) Methotrexate

D
) Prednisone

E
) Probenecid

8. A 32-year-old woman who is HIV positive has a CD4+ lymphocyte count of 800/mm3 (Normal ≥ 500). Her health maintenance regimen should include immunization against which of the following pathogens?

A
) Haemophilus influenzae type b

B
) Hepatitis A

C
) Influenza virus

D
) Neisseria meningitidis

E
) Streptococcus pyogenes (group A)

9. A 32-year-old woman comes to the physician because of bright red rectal bleeding and severe stabbing pain with each bowel movement over the past 2 weeks. She has blood-streaked stools, and there is blood on the toilet paper. Over the past 2 months, she has had mild constipation with no change in the caliber of the stool. Examination shows a small anal fissure at the posterior midline. Rectal examination is painful, but no abnormalities are detected except for a small amount of bright red blood from the fissure. Which of the following is the most appropriate next step in management?

A
) Anesthetic ointment and stool softeners

B
) Anal dilatation under anesthesia

C
) Debridement and closure of the fissure under anesthesia

D
) Surgical flaps

E
) Lateral internal sphincterotomy

10. A 28-year-old nulligravid woman comes for a routine health maintenance examination. She has had progressively severe dysmenorrhea over the past 6 months adequately controlled by nonsteroidal anti-inflammatory agents. Pelvic examination shows a normal vagina and cervix. The uterus is retroverted and fixed, and there is nodularity of the cul-de-sac. A 6-cm left adnexal mass is palpated. Transvaginal ultrasonography shows a 7-cm septated adnexal mass. Four weeks later, there is no change in the size of the adnexal mass. Which of the following is the most appropriate diagnostic test?

A
) Measurement of serum CA 125 level

B
) Barium enema

C
) CT scan of the pelvis

D
) MRI of the pelvis

E
) Laparoscopy

11. A 67-year-old woman is hospitalized because of abdominal pain and persistent copious vomiting for 24 hours. Two weeks ago, she was hospitalized for treatment of atrial fibrillation; after cardioversion to a normal sinus rhythm, she began treatment with warfarin. Yesterday at a follow-up visit, her INR was 6, and her medication was discontinued. She takes no other medications. Her temperature is 37 C (98.6 F), blood pressure is 100/78 mm Hg, pulse is 120/min and regular, and respirations are 20/min. The abdomen is distended and moderately tender; there is voluntary guarding in the epigastrium. There are no masses, organomegaly, or obvious hernias. Rectal examination shows no abnormalities. Test of the stool for occult blood is negative. Her hemoglobin level has decreased from 13 g/dL yesterday to 7.8 g/dL today. An ECG shows a normal sinus rhythm. Which of the following is the most likely explanation for this patient's abdominal symptoms?

A
) Internal small-bowel herniation

B
) Intestinal ischemia from a cardiac embolus

C
) Intramural hematoma of the proximal small bowel

D
) Intussusception of the small bowel

E
) Malrotation of the small bowel

12. A 32-year-old man with alcoholism is brought to the emergency department by friends because he has been unable to stand without support and has had "funny eye movements"; they report that he has been drinking approximately 18 beers daily over the past month and has been increasingly confused over the past 5 days. He is awake and confused but is noncombative. His speech is slurred, and his breath smells of alcohol. His temperature is 37.2 C (99 F), blood pressure is 180/60 mm Hg, pulse is 110/min, and respirations are 18/min. Physical examination shows sixth cranial nerve palsy, horizontal diplopia, strabismus, and an asymmetric horizontal-gaze evoked nystagmus. Neurologic examination shows no focal weakness or numbness. When helped up and told to walk, he has a broad-based, uncertain gait. When asked how he arrived at the emergency department, he relates that "I drove to this place to visit some friends." The most likely cause of these findings is a deficiency of which of the following?

A
) Folic acid

B
) Magnesium

C
) Vitamin B1 (thiamine)

D
) Vitamin B12 (cyanocobalamin)

E
) Zinc

13. A 32-year-old woman, gravida 2, para 2, comes to the physician because she has been amenorrheic for 4 months. Examination shows a well-estrogenized vagina and no evidence of virilization or other abnormalities. A serum pregnancy test is negative. She is given medroxyprogesterone and has the onset of bleeding 3 days later. Which of the following is the most likely cause of her condition?

A
) Anovulation

B
) Asherman's syndrome

C
) Hypopituitarism

D
) Menopause

E
) Premature ovarian failure

14.

A previously healthy 47-year-old woman comes to the emergency department because of a 36-hour history of nausea, vomiting, and abdominal pain that radiates to her back. Over the past 3 years, she has had intermittent episodes of cramping abdominal pain 1 to 2 hours after meals; the pain lasts for several hours and resolves spontaneously. She does not smoke and drinks one to two glasses of wine each evening. There is a family history of coronary artery disease and hypertension. Her temperature is 37 C (98.6 F), blood pressure is 100/60 mm Hg, pulse is 120/min, and respirations are 20/min. Abdominal examination shows moderate epigastric and right upper quadrant tenderness with no guarding or rebound; bowel sounds are decreased. Laboratory studies show:

15. A healthy 37-year-old primigravid woman at 12 weeks' gestation comes for a routine prenatal visit. The pregnancy was achieved by in vitro fertilization. She does not use tobacco, alcohol, or drugs. She is a hematologist and works 10 to 12 hours daily. Two previous ultrasonographies have shown a triplet gestation. She weighs 66 kg (145 lb) and is 178 cm (70 in) tall. Her blood pressure is 116/70 mm Hg, and pulse is 72/min. Examination shows a uterus consistent in size with a 16-week gestation. Her pelvis is normal-sized. This patient is at greatest risk for which of the following?

A
) Abruptio placentae

B
) Hepatitis B

C
) HIV infection

D
) Preterm labor

E
) Uterine rupture

16. A 67-year-old man is brought to the emergency department because of a 3-day history of fever and headache. Five years ago, he underwent placement of a mechanical aortic valve for treatment of sequelae of rheumatic fever. He appears ill. His temperature is 40 C (104 F), blood pressure is 110/65 mm Hg, pulse is 110/min, and respirations are 22/min. A grade 3/6, systolic ejection murmur is heard. Neurologic examination shows mild left hemiparesis. Babinski's sign is present on the left. There is no nuchal rigidity. This patient is at greatest risk for which of the following complications?

A
) Brain abscess

B
) Carotid artery occlusion

C
) Encephalitis

D
) Hydrocephalus

E
) Venous sinus thrombosis

17. A 67-year-old woman comes for a routine health maintenance examination. She drinks 1 ounce of alcohol daily. Her blood pressure is 138/62 mm Hg, pulse is 76/min and regular, and respirations are 14/min. The lungs are clear to auscultation. The remainder of the examination shows no abnormalities. Laboratory studies show:

Which of the following is the most appropriate next step in management?

A
) Measurement of serum alkaline phosphatase activity

B
) Measurement of serum parathyroid hormone level

C
) Measurement of serum vitamin D level

D
) Serum and urine protein electrophoresis

E
) X-ray film of the chest

F
) Skeletal survey

G
) Bone scan

The response options for the next two items are the same. You will be required to select one answer for each item in the set.

For each patient with papilledema, select the most likely diagnosis.

A
) Bacterial meningitis

B
) Cerebral infarction

C
) Cryptococcal meningitis

D
) Glioblastoma multiforme

E
) Herpes simplex encephalitis

F
) Hypertensive encephalopathy

G
) Idiopathic intracranial hypertension

H
) Intracerebral hemorrhage

I
) St. Louis encephalitis

18. A 25-year-old woman comes to the emergency department because of increasingly severe bifrontal headaches over the past 6 months. During this period, she has had transient episodes of blindness lasting 1 to 2 seconds. She has not had nausea or vomiting. She has a long-standing history of difficulty losing weight. She currently weighs 113 kg (250 lb) and is 152 cm (60 in) tall. Her blood pressure is 120/80 mm Hg. Visual field testing shows enlarged blind spots. The remainder of the neurologic examination shows normal findings. A CT scan of the head with and without contrast shows no abnormalities. Examination of the cerebrospinal fluid shows:

19. A 25-year-old man with a history of intravenous drug use comes to the emergency department because of a progressive diffuse headache, generalized malaise, and low-grade fever for 2 months. During this period, he has had a poor appetite resulting in a 6.8-kg (15-lb) weight loss. His temperature is 38 C (100.4 F). Examination shows ¬¬neck stiffness. Mental status examination shows no abnormalities. Cranial nerve examination shows weakness of the lateral rectus muscle on the right and bilateral papilledema. A CT scan of the head with and without contrast shows moderate ventricular enlargement. Examination of cerebrospinal fluid shows:

20. An asymptomatic 32-year-old woman comes for a routine health maintenance examination. Her mother and sister have a history of low back pain and disc herniation. The patient is a postal worker. She weighs 86 kg (190 lb) and is 165 cm (65 in) tall. Her blood pressure is 130/78 mm Hg, pulse is 74/min, and respirations are 16/min. Range of motion of the spine is normal and without pain. There is no scoliosis or excessive kyphosis of the back. Which of the following is the most effective strategy to decrease this patient's risk for developing low back pain?

A
) Change in job

B
) Limit physical activity

C
) Stretching exercises

D
) Weight-loss program

E
) Nonsteroidal anti-inflammatory drug therapy

F
) Prophylactic brace

21. Three days after being hospitalized for treatment of a hip fracture sustained in a fall, a 62-year-old woman becomes acutely short of breath and coughs up a small amount of blood-tinged sputum. She appears anxious. Her blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 24/min. Examination shows no other abnormalities. Arterial blood gas analysis on 40% oxygen by face mask shows:

pH 7.40
PCO2 38 mm Hg
PO2 70 mm Hg

Ventilation-perfusion lung scans show multiple segmental areas of mismatch on the right. Which of the following is the most appropriate next step in management?

A
) Pulmonary angiography

B
) Dopamine therapy

C
) Heparin therapy

D
) Urokinase therapy

E
) Intubation

22. A 24-year-old man is brought to the emergency department by police 1 hour after his ex-wife found him stumbling around in the yard. His blood pressure is 100/70 mm Hg, pulse is 90/min, and respirations are 16/min. The pupils are equal and reactive to light; the sclerae are injected. During the examination, he laughs without obvious reason, makes religious statements, and asks if there is anything to eat or drink. Mental status examination shows a broad range of affect; there is no evidence of thought disorder except for mild paranoia. Which of the following is the most appropriate next step in management?

A
) Observation in the emergency department

B
) Intramuscular administration of naloxone

C
) Intravenous administration of 50% dextrose

D
) Intravenous administration of lorazepam

E
) Oral administration of chlorpromazine

23. A 17-year-old boy sustains a head injury and loses consciousness after diving into a freshwater lake from a platform. After being submerged for 3 minutes, he is rescued. He is initially cyanotic but then begins to cough and breathe spontaneously after a 5-minute resuscitation. Over the next 36 hours, which of the following complications is most likely?

A
) Acute respiratory distress syndrome

B
) Bacteremia

C
) Bacterial pneumonia

D
) Hypernatremia

E
) Metabolic alkalosis

24. A 15-year-old boy is brought to the emergency department 30 minutes after being involved in a motor vehicle collision. He was the unrestrained passenger. On arrival, he is disoriented. His blood pressure is 80/40 mm Hg, pulse is 112/min, and respirations are 24/min. There is no jugular venous distention. Examination of the chest shows dullness to percussion and decreased breath sounds over the right hemithorax. Which of the following is the most likely diagnosis?

A
) Diaphragmatic rupture

B
) Flail chest

C
) Hemothorax

D
) Massive aspiration

E
) Pneumothorax

25. An 18-year-old man comes to the physician for an initial examination because of a 3-year history of fatigue and migrating joint pain. He has brought a large folder containing information about previous medical consultations, laboratory tests, and x-ray films. He takes no medications. He weighs 50 kg (110 lb) and is 173 cm (68 in) tall. Physical examination shows no other abnormalities. On mental status examination, he is preoccupied with his symptoms. When asked about his mood, he states that the future appears bleak, and that he is too tired to think about it. Which of the following is the most appropriate next step in management?

A
) Ask about further symptoms of obsessions and compulsions

B
) Ask about sexual history including sexual orientation and practices

C
) Ask about suicidal feelings

D
) Ask about travel history over the past 6 months

E
) Obtain a detailed exercise history

F
) Measurement of serum Lyme (Borrelia burgdorferi) antibody level

G
) Urine toxicology screening

26. An 80-year-old woman has had bleeding gums for 3 weeks. Her diet has consisted of only tea and toast for 2 years. She appears thin and weak. Vital signs are normal. Her gums are hypertrophied and exude blood with pressure. There are ecchymoses of the inner thighs and small hemorrhages around the hair follicles. The remainder of the examination shows normal findings. Supplementation with which of the following vitamins is most likely to have prevented this condition?

A
) A

B
) B12 (cyanocobalamin)

C
) C

D
) D

E
) E

27. A 30-year-old woman, gravida 2, para 1, is brought to the emergency department in labor. An episiotomy is performed. Following delivery of the head, the shoulders do not follow with the usual traction and maternal pushing. Which of the following is the most appropriate next step in management?

A
) Flexing the woman's knees toward her shoulders

B
) More forceful traction and fundal pressure

C
) Delivering the posterior arm

D
) Rotating the head 180 degrees

E
) Symphysiotomy

28.

A 32-year-old man comes to the physician because of a 3-day history of low back pain, urinary hesitancy, and pain with urination. He has had several similar episodes over the past 3 years. He has not had any urethral discharge or recent sexual contacts. His temperature is 37.2 C (98.9 F), and blood pressure is 126/76 mm Hg. The lungs are clear to auscultation; there is no costovertebral angle tenderness. Abdominal examination shows no tenderness or masses. There is no tenderness to palpation of the lower back. Straight-leg raising to 90 degrees is negative. There are no motor or sensory deficits in the lower extremities. Rectal examination shows a diffuse, minimally enlarged, tender prostate with no masses. Laboratory studies show:

29. A 16-year-old boy with neurofibromatosis is brought for a follow-up examination. His uncle also has neurofibromatosis. He has a 1-year history of headaches during which his parents say he appears pale. Six months ago, he underwent operative treatment for an optic nerve glioma. His blood pressure is 164/105 mm Hg, pulse is 102/min, and respirations are 14/min. The thyroid glands are not enlarged. No murmurs are heard, and radial pulses are equal. Abdominal examination shows no abnormalities. Which of the following is the most likely cause of this patient's high blood pressure?

A
) Catecholamine-producing tumor

B
) Carcinoma of the thyroid gland

C
) Essential hypertension

D
) Overproduction of aldosterone from an adrenal adenoma

E
) Postsubclavian coarctation of the aorta

30. A 14-month-old girl is brought to the physician because of a 14-hour history of irritability and episodes of drawing her knees toward her chest. During this period, she has vomited nonbilious fluid twice and had a bowel movement containing a small amount of blood. She had an upper respiratory tract infection 2 weeks ago. She is listless except for intermittent episodes of discomfort. Her temperature is 38 C (100.4 F). Abdominal examination shows right-sided tenderness without guarding or rebound; bowel sounds are present. Rectal examination shows bright red blood and mucus. An x-ray film of the abdomen shows no abnormalities. Which of the following is the most appropriate next step in management?

A
) X-ray film of the upper gastrointestinal tract with contrast

B
) Water-soluble contrast enema

C
) Corticosteroid enemas

D
) Admission to the hospital for total parenteral nutrition

E
) Immediate laparotomy

31. An asymptomatic 47-year-old man comes for a preemployment examination. He has never been hospitalized. He is a computer programmer, and he plays handball once weekly. His maternal grandmother had type 2 diabetes mellitus, and a paternal uncle had heart disease. The patient's blood pressure is 126/80 mm Hg. Examination shows no abnormalities. His total serum cholesterol level is 225 mg/dL. Which of the following is the most appropriate next step in management?

A
) Step 2 American Heart Association cardiac diet

B
) Serum lipid studies while fasting

C
) Exercise stress test

D
) Oral cholestyramine and niacin therapy

E
) Oral pravastatin therapy at bedtime

32. A 25-year-old woman comes to the physician because of a 3-month history of the unexplained urge to eat a few tablespoons of cornstarch daily. The amount of cornstarch ingested has increased gradually during this time. She has leiomyomata uteri; she is otherwise healthy. Her weight is unchanged from her last visit 1 year ago; she weighs 61 kg (135 lb) and is 168 cm (66 in) tall. Her blood pressure is 120/80 mm Hg, and pulse is 100/min. Physical examination shows mild pallor. Neurologic examination shows no abnormalities. She is embarrassed about her problem. She has no compulsive behavior or obsessive thoughts. An ECG shows sinus tachycardia. Which of the following is the most appropriate next step in management?

A
) Psychiatric assessment

B
) Complete blood count

C
) Thyroid function studies

D
) Urine toxicology screening

E
) Admission to an eating disorders clinic

F
) Antipsychotic therapy

G
) Folic acid supplementation

H
) Selective serotonin reuptake inhibitor therapy

33. A 30-year-old woman comes to the physician for a follow-up examination 4 months after starting treatment with lithium carbonate; during this period she has had a 3.2-kg (7-lb) weight gain. Her medication was prescribed soon after the birth of her son to treat racing thoughts, increased spending, and overtalkativeness; she has had difficulty sleeping for more than 2 hours nightly. Her symptoms decreased after 2 weeks of lithium carbonate therapy. She continues to take lithium carbonate (300 mg three times daily). Her temperature is 37 C (98.6 F), blood pressure is 120/80 mm Hg, and pulse is 70/min. Examination shows normal findings. The most appropriate next step is measurement of which of the following?

A
) Fasting serum glucose level

B
) Leukocyte count

C
) Serum alkaline phosphatase activity

D
) Serum creatinine level

E
) Serum thyroid-stimulating hormone level

34. On a routine examination, a 2-year-old boy has a hemoglobin level of 10.5 g/dL, hematocrit of 30%, and mean corpuscular volume of 72 μm3. He drinks four to five 8-oz bottles of milk daily. He maintains a regular diet but does not eat vegetables. Which of the following is the most likely diagnosis?

A
) Folic acid deficiency

B
) Iron deficiency

C
) Sickle cell disease

D
) Thalassemia

E
) Vitamin B6 deficiency

35. A 57-year-old man is brought to the physician by his wife because his skin has appeared yellow for 3 weeks. Examination shows jaundice and scleral icterus. His total serum bilirubin level is 8 mg/dL with a direct component of 6.2 mg/dL. A CT scan of the abdomen shows a large lesion in the head of the pancreas. When the results are initially discussed, the patient says that he does not want to hear the report, and his wife agrees to abide by his wishes. Which of the following is the most appropriate course of action?

A
) Withhold the results as the patient wishes

B
) Contact the patient's children to discuss the results

C
) Consult with the hospital ethics committee

D
) Insist on telling the patient the results

E
) Refer him to another physician

36. A previously healthy 52-year-old man comes to the physician because of a 3-month history of increased urinary volume and increased urinary frequency at night. He has had a 6.8-kg (15-lb) weight loss during this period despite no change in appetite. His father has hypertension, and his mother has hypertension and type 2 diabetes mellitus. He currently weighs 95 kg (210 lb) and is 178 cm (70 in) tall. His blood pressure is 160/85 mm Hg in both arms. Examination shows no other abnormalities. His nonfasting serum glucose level is 280 mg/dL. Which of the following serum levels is most likely to be increased in this patient?

A
) Bicarbonate

B
) Glucagon

C
) HDL-cholesterol

D
) Insulin

E
) Ketones

37. Three days after hospitalization for heparin treatment of deep venous thrombosis of a left superficial femoral vein, a 52-year-old woman has prolonged bleeding from a venipuncture site. She had a pulmonary embolus 2 years ago. Her temperature is 37.5 C (99.5 F). Examination shows multiple ecchymoses at the venipuncture sites with oozing of fresh blood. Laboratory studies show:

38. A 37-year-old woman comes to the physician because of an itchy rash over her trunk for 2 weeks. She has not had fever, chills, shortness of breath, chest pain, or gastrointestinal symptoms. She has a history of recurrent urinary tract infections and has been taking trimethoprim-sulfamethoxazole prophylaxis for the past year. She is in mild distress. Her temperature is 37.5 C (99.5 F), blood pressure is 96/62 mm Hg, pulse is 78/min, and respirations are 14/min. Examination shows a maculopapular erythematous rash over the trunk. Laboratory studies show:

39. A 19-year-old primigravid woman at 34 weeks' gestation comes to the physician for a routine prenatal visit. Her pregnancy has been uncomplicated. She has no history of serious illness. She takes no medications and has no known allergies. Examination shows a uterus consistent in size with a 34-week gestation. A routine clean-catch urine culture grows greater than 100,000 colonies/mL of Escherichia coli. Which of the following is the most appropriate pharmacotherapy?

A
) Ampicillin

B
) Ciprofloxacin

C
) Clindamycin

D
) Doxycycline

E
) Trimethoprim-sulfamethoxazole

40. A 13-year-old girl is brought for a well-child examination. Menses have occurred every other month since menarche 10 months ago. Her last menstrual period was 1 week ago. She is not sexually active. Sexual development is Tanner stage 3. Examination shows no abnormalities. Which of the following is the most appropriate next step in management?

41. A 72-year-old man comes to the emergency department after a 5-minute episode of blindness in the right eye. Over the past month, he has had headache and pain in the jaw with chewing. His temperature is 38.1 C (100.6 F). Examination shows tender, nodular temporal arteries with decreased pulses. His erythrocyte sedimentation rate is 92 mm/h. Which of the following is the most appropriate immediate step in management?

A
) Carotid ultrasonography

B
) Aspirin therapy

C
) Cefotaxime therapy

D
) Corticosteroid therapy

E
) Temporal artery biopsy

42. A 42-year-old man comes for a routine health maintenance examination. There is no family history of coronary artery disease, and he does not smoke. His weight is appropriate for his height. His blood pressure is 120/80 mm Hg. Serum lipid studies show a total cholesterol level of 190 mg/dL, HDL-cholesterol level of 40 mg/dL, and triglyceride level of 150 mg/dL. Which of the following is the most appropriate next step in management?

A
) Recommend the Step 2 National Cholesterol Education Program diet

B
) Measure serum LDL-cholesterol level now

C
) Measure total serum cholesterol level in 5 years

D
) Prescribe prophylactic aspirin

E
) Begin treatment with lovastatin

43. A 28-month-old boy has a history of cyanosis since birth with episodes of syncope. Examination shows cyanosis and clubbing. The lungs are clear to auscultation. There is a right ventricular heave, a systolic click, a single S2, and a grade 3/6 systolic murmur. Which of the following is the most likely diagnosis?

A
) Bicuspid aortic valve

B
) Coarctation of the aorta

C
) Mitral stenosis

D
) Patent ductus arteriosus

E
) Tetralogy of Fallot

44. A healthy 18-year-old woman comes for a routine health maintenance examination. Menses occur at regular 28-day intervals. Her last menstrual period was 2 weeks ago. She is sexually active with one partner, and she and her partner use condoms inconsistently for contraception. Her maternal grandmother was diagnosed with breast cancer at the age of 65 years, her paternal grandfather was diagnosed with colon cancer at the age of 72 years, and her maternal grandfather died of a myocardial infarction at the age of 66 years. Examination shows no abnormalities. Which of the following is the most appropriate screening test for this patient?

A
) Complete blood count

B
) Fasting serum lipid studies

C
) Test of the stool for occult blood

D
) Testing for Neisseria gonorrhoeae and Chlamydia trachomatis

E
) Urinalysis

The response options for the next two items are the same. You will be required to select one answer for each item in the set.

For each child with fever and cough, select the most likely diagnosis.

A
) α1-Antitrypsin deficiency

B
) Cystic fibrosis

C
) Pneumothorax

D
) Pulmonary alveolar proteinosis

E
) Pulmonary aspergillosis

F
) Pulmonary hemorrhage

G
) Pulmonary tuberculosis

45. A 20-month-old girl is brought to the physician because of fever and cough for 2 days. She has had several similar episodes since the age of 4 months. Three months ago, she and her family visited her grandmother in Finland for 2 weeks. She is at the 25th percentile for length and 5th percentile for weight. She appears thin and pale. Her temperature is 38 C (100.4 F), pulse is 150/min, and respirations are 40/min. Examination shows mild clubbing. Wheezing and bilateral crackles are heard at the lung bases. An x-ray film of the chest shows streaky densities bilaterally with mild hyperinflation.

For each child with fever and cough, select the most likely diagnosis.

A
) α1-Antitrypsin deficiency

B
) Cystic fibrosis

C
) Pneumothorax

D
) Pulmonary alveolar proteinosis

E
) Pulmonary aspergillosis

F
) Pulmonary hemorrhage

G
) Pulmonary tuberculosis

46. A previously healthy 16-year-old boy is brought to the physician because of fever and cough with right-sided chest pain for 2 weeks. Six months ago, he visited his grandparents in Albania for 2 weeks. He weighs 54 kg (120 lb) and is 173 cm (68 in) tall. He appears thin and pale. His temperature is 38.2 C (100.8 F), pulse is 76/min, and respirations are 36/min. Examination shows shallow respirations with decreased breath sounds at the right lung base. An x-ray film of the chest shows a right pleural effusion and hilar adenopathy.
__________________________________________________________________________________________________________________________________

Section 4:--

1. A previously healthy 52-year-old man comes to the emergency department because of hiccups for 1 week. He has smoked two packs of cigarettes daily for 30 years. He does not drink alcohol. He is alert and oriented. His temperature is 37 C (98.6 F), blood pressure is 150/95 mm Hg, pulse is 70/min, and respirations are 12/min. Physical and neurologic examinations show no abnormalities. His serum sodium level is 120 mEq/L. An x-ray film of the chest shows a right hilar mass. Which of the following is the most appropriate next step in treatment?

A
) Bisphosphonate therapy

B
) Calcitonin therapy

C
) Calcium therapy

D
) Dexamethasone therapy

E
) 5% Dextrose in 0.225% saline therapy

F
) 5% Dextrose in 0.45% saline therapy

G
) 5% Dextrose in water therapy

H
) Fluid restriction

I
) Hydrocortisone therapy

J
) Lactated Ringer's solution

K
) Mannitol therapy

L
) Potassium therapy

M
) 0.9% Saline therapy

N
) 3% Saline therapy

O
) Sodium bicarbonate therapy

2. A 67-year-old man comes to the physician because of a 6-month history of double vision, slurred speech, and difficulty swallowing liquids. Initially, his symptoms were intermittent but now occur daily and are worse at the end of the day. Over the past week, he has had shortness of breath with exertion. He has pernicious anemia treated with monthly vitamin B12 (cyanocobalamin) injections and autoimmune thyroid disease currently treated with thyroid replacement therapy. Examination shows bilateral ptosis and disconjugate gaze. There is bilateral facial weakness and hypernasal speech. The tongue is weak, and the gag reflex is reduced. Muscle strength is 4/5 in the proximal muscles of the upper and lower extremities. Deep tendon reflexes are 2+ diffusely. Babinski's sign is absent. Sensory examination shows no abnormalities. A CT scan of the chest is shown. Which of the following is the most likely diagnosis of this patient's intrathoracic lesion?

A
) Aspiration pneumonia

B
) Bronchogenic carcinoma

C
) Lung metastasis

D
) Sarcoidosis

E
) Thymoma

F
) Thyroid carcinoma

3. A 32-year-old man receiving intensive chemotherapy for Hodgkin's disease has a temperature of 39 C (102.2 F). His respirations are 40/min. Widespread crackles are heard in all lung fields. An x-ray film of the chest shows a diffuse alveolar and interstitial pattern. Which of the following is the most likely causal organism?

A
) Aspergillus species

B
) Candida albicans

C
) Coccidioides immitis

D
) Pneumocystis carinii

E
) Streptococcus pneumoniae

4. A 20-year-old African American man with sickle cell disease comes to the physician because of a 1-week history of shortness of breath on exertion, fatigue, and generalized weakness. He has had no fever, chills, night sweats, or cough productive of sputum. His only medication is oxycodone for joint pain. He weighs 68 kg (150 lb) and is 168 cm (66 in) tall. His temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, pulse is 76/min, and respirations are 18/min. Examination shows no abnormalities. Laboratory studies show:

Which of the following is the most likely mechanism for these findings?

A
) Adverse drug reaction

B
) Atrophy of gastric mucosa

C
) Bacterial overgrowth in the small intestine

D
) Increased demand for folic acid

E
) Increased demand for vitamin B12 (cyanocobalamin)

F
) Malabsorption

G
) Vitamin B1 (thiamine) deficiency

5. A 44-year-old woman comes to the emergency department 2 days after being discharged from the hospital for abdominal pain; an exploratory laparoscopy showed no abnormalities. Over the past 5 years, she had been admitted to the hospital numerous times for the evaluation of a variety of symptoms; all work-ups had been negative. Her temperature is 39.2 C (102.6 F). Examination shows a reddened, indurated laparoscopic wound. She is admitted to the hospital and given intravenous antibiotics. On the second hospital day, a nurse witnesses the patient rubbing saliva into her laparoscopy site. Which of the following is the most likely diagnosis?

A
) Adjustment disorder with disturbance of conduct

B
) Conduct disorder

C
) Conversion disorder

D
) Factitious disorder

E
) Hypochondriasis

F
) Major depressive disorder

G
) Oppositional defiant disorder

H
) Somatization disorder

6. A 37-year-old woman is brought to the emergency department because she has been unable to see out of her right eye since awakening 2 hours ago. She states that any movement of the eye is painful. Examination shows visual acuity of 20/200 in the right eye and 20/20 in the left eye. The optic fundi are normal. The left pupil reacts normally to light. The right pupil is poorly reactive to direct light. The remainder of the eye examination shows no abnormalities. Which of the following is the most likely site of the lesion?

A
) Left optic nerve

B
) Left optic radiation

C
) Left optic tract

D
) Left visual cortex

E
) Optic chiasm

F
) Retina

G
) Right optic nerve

H
) Right optic radiation

I
) Right optic tract

J
) Right visual cortex

The response options for the next two items are the same. You will be required to select one answer for each item in the set.

For each patient with peripheral nerve dysfunction, select the most likely site of nerve injury.

A
) Axillary nerve

B
) Cervical nerve root at the cervical foramen

C
) Long thoracic nerve

D
) Median nerve above the elbow

E
) Median nerve at the elbow

F
) Median nerve at the wrist

G
) Musculocutaneous nerve above the elbow

H
) Musculocutaneous nerve at the elbow

I
) Musculocutaneous nerve at the wrist

J
) Radial nerve above the elbow

K
) Radial nerve at the elbow

L
) Radial nerve at the wrist

M
) Suprascapular nerve

N
) Thoracodorsal nerve

O
) Ulnar nerve above the elbow

P
) Ulnar nerve at the elbow

Q
) Ulnar nerve at the wrist

7.

A previously healthy 42-year-old carpenter comes to the physician because of a 6-month history of pain and numbness in his dominant hand that awakens him at night. He describes numbness in his long and index fingers after driving for extended periods of time. Examination shows minimal atrophy of the thenar muscles. There is normal sensation to light touch on the little finger and the palm of the right hand. Sensation to light touch is decreased at the tip of the thumb, index finger, and long finger. X-ray films of the right elbow and wrist show no abnormalities.

For each patient with peripheral nerve dysfunction, select the most likely site of nerve injury.

A
) Axillary nerve

B
) Cervical nerve root at the cervical foramen

C
) Long thoracic nerve

D
) Median nerve above the elbow

E
) Median nerve at the elbow

F
) Median nerve at the wrist

G
) Musculocutaneous nerve above the elbow

H
) Musculocutaneous nerve at the elbow

I
) Musculocutaneous nerve at the wrist

J
) Radial nerve above the elbow

K
) Radial nerve at the elbow

L
) Radial nerve at the wrist

M
) Suprascapular nerve

N
) Thoracodorsal nerve

O
) Ulnar nerve above the elbow

P
) Ulnar nerve at the elbow

Q
) Ulnar nerve at the wrist

8. A previously healthy 37-year-old man comes to the physician because of a 2-month history of pain in the forearm and little finger of his dominant hand; he has been working as a receptionist for 6 months. He describes numbness in his little finger and weakness of his grip. There is decreased sensation to light touch at the tip of the little finger. Paresthesias are elicited with compression of the cubital tunnel.

9. A 3-month-old boy is brought for a well-child examination. He has poor head control. Examination shows generalized hypotonia. The point of maximal impulse is at the left anterior axillary line. The liver edge is palpated 4 cm below the right costal margin. The spleen is not palpable. Which of the following is the most likely diagnosis?

A
) Congenital muscular dystrophy

B
) Glycogen storage disease, type II (Pompe's disease)

C
) GM1 gangliosidosis

D
) Infant botulism

E
) Ventricular septal defect

10. Over the past 3 months, a 30-year-old woman has had intermittent episodes of headache, palpitations, sweating, and irritability. Her blood pressure is 150/100 mm Hg while supine and 149/100 mm Hg while standing, and pulse is 90/min while supine and 110/min while standing. Examination shows no abnormalities except for pallor. Which of the following is the most likely location of this patient's lesion?

A
) Adrenal gland

B
) Brain

C
) Heart

D
) Kidney

E
) Thyroid gland

11. A 19-year-old man is brought to the emergency department 45 minutes after sustaining a single, large stab wound to the right upper quadrant of the abdomen. He is obtunded. His blood pressure is 60/palpable mm Hg, and pulse is 148/min. Breath sounds are equal bilaterally. Examination shows a 4-cm laceration in the right upper quadrant in the midclavicular line. The abdomen is distended. Which of the following is the most appropriate next step in management?

A
) X-ray films of the abdomen and pelvis

B
) Angiography

C
) Contrast study of the wound tract

D
) CT scan of the abdomen

E
) CT scan of the chest

F
) Laparoscopy

G
) Peritoneal lavage

H
) Laparotomy

I
) Local wound exploration

12. A 52-year-old woman comes to the physician because of decreased libido; this symptom began 8 months ago, after she underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for leiomyomata uteri and menorrhagia. She has been taking hormone replacement therapy with conjugated estrogen since the operation. Examination shows a moist, rugated vagina. Which of the following is the most likely cause of these findings?

A
) Decreased androgens

B
) Decreased estrogen

C
) Decreased follicle-stimulating hormone (FSH)

D
) Decreased luteinizing hormone (LH)

E
) Decreased progesterone

F
) Decreased prolactin

G
) Increased androgens

H
) Increased estrogen

I
) Increased FSH

J
) Increased LH

K
) Increased progesterone

L
) Increased prolactin

13.

A 7-day-old newborn is brought for a well-child examination. He was born at home. His mother has taken acetaminophen for perineal discomfort. The newborn is breast-feeding well. He is at the 75th percentile for length and weight. Examination shows no abnormalities. After vaccination with hepatitis B, he has prolonged bleeding at the injection site. There is no family history of excessive bleeding. Laboratory studies show:

Which of the following is the most likely mechanism for these findings?

A
) Autoimmunization

B
) Bacterial toxic effect

C
) Factor VIII deficiency

D
) Factor IX deficiency

E
) Immunoglobulin deficiency

F
) Iron deficiency

G
) Pharmacologic effect

H
) Viral toxic effect

I
) Vitamin deficiency

J
) Zinc deficiency

14.

A 67-year-old man with long-standing signs and symptoms of congestive heart failure is admitted to the hospital because of progressive shortness of breath. Examination shows no other abnormalities. An x-ray film of the chest shows cardiomegaly, cephalization of blood vessels, and a right-sided pleural effusion. Which of the following sets of pleural fluid findings is most likely in this patient?

15. For 8 weeks, a 52-year-old man with a 5-year history of type 2 diabetes mellitus has had deep burning pain in the ball of his right foot and big toe when the foot is raised above chest level. He also has cramping in his right calf when he walks more than 50 feet. He has smoked two packs of cigarettes daily for 30 years. Femoral pulses are palpable; pedal pulses are absent. Which of the following is the most likely diagnosis?

A
) Aortoiliac stenosis

B
) Femoral popliteal stenosis

C
) Mononeuropathy

D
) Vasculitis

E
) Venous stasis

16. A 1-year study of a new drug to treat hypertension is conducted. One hundred patients with hypertension are enrolled; 50 patients are given the new drug and another 50 patients are given hydrochlorothiazide. All patients completed the trial. One noted unexpected effect is increased growth of scalp hair which occurred in those taking the new drug, a nonstatistically significant difference (p>0.10). This effect has also been reported in studies of other similar drugs in the new therapeutic class. The investigators of the study concluded that the new drug did not cause hair growth. Which of the following features of this study is most likely to affect the validity of this conclusion?

A
) Differential follow-up

B
) Lead time bias

C
) Length of the study

D
) Sample size

E
) Self-selection

17. A 38-year-old woman, gravida 2, para 1, at 38 weeks' gestation has had no fetal movement for 36 hours. Her prenatal course, prenatal tests, and fetal growth have been normal. Fetal heart tones are heard by Doppler. Which of the following is the most appropriate next step in management?

A
) Routine prenatal visit in 1 week

B
) Maternal hydration

C
) Nonstress test

D
) Immediate induction of labor

E
) Amniocentesis

18. A healthy 7-year-old boy is brought to the physician 1 week after he was exposed for several hours to a child with chickenpox. The patient and his healthy sister have not had chickenpox. They have not received varicella vaccine. Which of the following is the most appropriate management for the patient and his sister at this time?

A
) Administer acyclovir as prophylaxis

B
) Administer immune globulin, intravenously

C
) Administer aspirin therapy if vesicles appear

D
) Advise the parents to keep the siblings home from school to prevent exposing their classmates

E
) Inform the parents that a vesicular rash may appear at any time over the next 2 weeks

19. A 6-year-old boy is brought to the physician by his mother because of progressive visual loss over the past year. Over the past 2 years, he has had deterioration of his hearing, speech, writing, and intellectual performance. His maternal uncle had similar symptoms. Visual acuity is 20/200 bilaterally. Funduscopic examination shows optic atrophy. His hearing is markedly impaired. There is weakness and spasticity of all extremities. Deep tendon reflexes are extremely hyperactive. Babinski's sign is present bilaterally. On mental status examination, he is not oriented to place, year, month, or the names of his siblings. An MRI of the brain shows marked symmetric white matter disease involving all lobes. Diagnostic studies are most likely to show which of the following?

A
) Abnormally decreased serum cholesterol level

B
) Acanthocytes on blood smear

C
) An excess of very long chain fatty acids

D
) Normal nerve conduction studies

E
) Vitamin E deficiency

20. A 22-year-old primigravid woman at 16 weeks' gestation is brought to the emergency department because of progressive shortness of breath over the past 48 hours. Her temperature is 37 C (98.6 F), blood pressure is 120/70 mm Hg, pulse is 100/min, and respirations are 24/min. Scattered wheezes are heard. Pelvic examination shows a uterus that extends to the umbilicus. Fetal heart tones are absent. Her hematocrit is 32%, leukocyte count is 11,000/mm3, and serum β-hCG level is 300,000 mIU/mL. Pulse oximetry on room air shows an oxygen saturation of 92%. An x-ray film of the chest shows multiple round densities throughout all lung fields. Which of the following is the most likely diagnosis?

A
) Bacterial pneumonia

B
) Choriocarcinoma

C
) Pulmonary embolism

D
) Tuberculosis

E
) Viral pneumonia

21. A 42-year-old man comes to the physician because of progressive swelling of the legs over the past 2 months. He has a history of stage IIA Hodgkin's disease treated 1 year ago with radiation therapy to the neck and chest. His temperature is 37 C (98.6 F), blood pressure is 102/80 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows jugular venous distention that increases with inspiration. The lungs are clear to auscultation. Cardiac examination shows a nondisplaced point of maximal impulse; heart sounds are distant. An early diastolic sound is heard at the apex. Abdominal examination shows mild distention with shifting dullness. The liver is pulsatile, and its edge is palpated 4 cm below the right costal margin. There is 2+ peripheral edema extending up to the knees. Which of the following is the most likely mechanism of this patient's increased central venous pressure?

A
) Constrictive pericarditis

B
) Cor pulmonale

C
) Left-sided congestive heart failure

D
) Mitral stenosis

E
) Tricuspid stenosis

22. A 5-year-old boy is brought to the emergency department 30 minutes after he fainted at home after standing up from a sitting position. His symptoms began 3 days ago with diarrhea and vomiting. He has had no urine output for 18 hours. He is alert but quiet. His temperature is 37.5 C (99.5 F), blood pressure is 75/45 mm Hg, pulse is 120/min, and respirations are 28/min. Examination shows dry lips and tenting of the skin. There is no abdominal tenderness. Bowel sounds are hyperactive. The remainder of the examination shows no abnormalities. His capillary refill time is 5 seconds. Intravenous bolus doses of 0.9% saline are administered. Bladder catheterization yields 5 mL of urine. Urinalysis is most likely to show which of the following?

A
) Blood

B
) Erythrocyte casts

C
) Hyaline casts

D
) Leukocyte casts

E
) Oxalate crystals

23.

A 2-year-old boy is brought to the physician because of fever and cough for 2 days. He had Streptococcus pneumoniae meningitis at the age of 1 year, S. pneumoniae bacteremia at the age of 18 months, and pneumonia at the age of 22 months. Two maternal uncles died before the age of 2 years from "infection." His temperature is 39.8 C (103.6 F), pulse is 150/min, and respirations are 60/min. Examination shows subcostal retractions on inspiration. Laboratory studies show:

A previously healthy 13-year-old girl is brought to the physician because of a 2-month history of intermittent abdominal pain and loose stools. She has had a 2.3-kg (5-lb) weight loss during this period due to a decreased appetite, but she drinks up to 1 liter of fruit juice daily. At her last visit 9 months ago, she was at the 50th percentile for height and the 50th percentile for weight. She is now at the 50th percentile for height and the 10th percentile for weight. Her temperature is 37.8 C (100 F), pulse is 80/min, and respirations are 18/min. Examination shows no other abnormalities. Test of the stool for occult blood is positive. Laboratory studies show:

A barium enema shows patches of ulcerations along the proximal colon with reflux of dye into the terminal ileum. Which of the following is the most appropriate next step in management?

A
) Eliminate fruit juice from the patient's diet

B
) Switch to a gluten-free diet

C
) H2- receptor blocking agent therapy

D
) Prednisone and aminosalicylate therapy

E
) Bowel resection

25. An asymptomatic 57-year-old man comes to the physician for a routine health maintenance examination. He has smoked one pack of cigarettes daily for 37 years. His blood pressure is 180/112 mm Hg, and pulse is 82/min. Abdominal examination shows a bruit in the right upper quadrant and no masses. His hematocrit is 42%, serum urea nitrogen (BUN) level is 23 mg/dL, and serum creatinine level is 1.4 mg/dL. Which of the following is the most likely cause of this patient's bruit?

A
) Accumulation of lipids in the arterial wall

B
) Hypertrophy of the arterial wall media

C
) Infiltration of arterial wall by giant cells

D
) Infiltration of round cells in the arterial wall

E
) Reflex vasodilation

26. An otherwise healthy 4-month-old girl is brought to the physician because of a birthmark on her arm that has increased in size over the past several weeks. Examination shows a 3 x 2-cm, bright red, raised, soft, nontender, compressible patch over the left forearm. Which of the following is the most appropriate next step in management?

A
) Topical corticosteroid therapy

B
) Biopsy

C
) Laser therapy

D
) Excision

E
) No intervention is necessary

27. A 7-year-old girl is brought to the physician in September because of fever and sore throat for 1 day. She is in the third week of second grade. Her temperature is 38.6 C (101.5 F). Examination shows an erythematous pharynx and slightly enlarged tonsils without exudate. There is no significant cervical lymphadenopathy. A rapid test for group A streptococcus is negative. Which of the following is the most appropriate next step in management?

A
) Monospot test

B
) Throat culture

C
) Intramuscular penicillin therapy

D
) Oral erythromycin therapy

E
) Oral penicillin therapy

The response options for the next two items are the same. You will be required to select one answer for each item in the set.

For each patient with weakness, select the most appropriate test to establish the cause of the condition.

A
) Brain stem auditory evoked potentials

B
) Carotid ultrasonography

C
) Chromosomal analysis for trinucleotide repeat

D
) Electroencephalography

E
) Electromyography and nerve conduction studies

F
) MRI of the spine

G
) Muscle biopsy

H
) Repetitive nerve stimulation

I
) Somatosensory evoked potentials

J
) SPECT scan

K
) Temporal artery biopsy

L
) Visual evoked potentials

28. A 57-year-old man is brought to the emergency department 6 hours after the onset of weakness of his right face, arm, and leg. Three days ago, he had an episode of sudden visual loss in his left eye that he describes as "a shade coming down." The episode resolved completely within 10 minutes. He has hypertension and type 2 diabetes mellitus, both poorly controlled with lisinopril and glyburide. Examination shows expressive aphasia and right lower facial droop. There is moderate weakness on the right, worse in the upper extremity than the lower extremity. Deep tendon reflexes are 3+ in the right extremities and 2+ in the left extremities. Babinski's sign is present on the right. Sensory examination shows no abnormalities.

For each patient with weakness, select the most appropriate test to establish the cause of the condition.

A
) Brain stem auditory evoked potentials

B
) Carotid ultrasonography

C
) Chromosomal analysis for trinucleotide repeat

D
) Electroencephalography

E
) Electromyography and nerve conduction studies

F
) MRI of the spine

G
) Muscle biopsy

H
) Repetitive nerve stimulation

I
) Somatosensory evoked potentials

J
) SPECT scan

K
) Temporal artery biopsy

L
) Visual evoked potentials

29. A previously healthy 27-year-old woman is brought to the emergency department because of a 2-day history of weakness of her arms and legs and numbness of her hands and feet and a 4-hour history of mild shortness of breath while supine. The weakness began in her feet and has progressed to involve the hands. She describes a sensation of "electrical shocks" extending from the buttocks to the feet. Today, she tripped and fell several times and was unable to button clothes or hold utensils. Three weeks ago, she had a mild upper gastrointestinal illness that resolved within 5 days. Her respirations are 20/min and shallow. There is mild facial weakness; cranial nerves are otherwise intact. Muscle strength in the upper and lower extremities is 4/5 proximally and 2/5 distally. There is areflexia. Babinski's sign is absent bilaterally. Sensation to vibration is slightly decreased at the fingers and toes.

30.

A 72-year-old man comes to the physician with his wife because of chronic abdominal pain and headaches for 4 months. His wife states that he has become more forgetful over the past 6 months. He has a history of gout. He has smoked one pack of cigarettes daily for 50 years and drinks 10 oz of homemade whiskey daily. He takes no medications. His temperature is 36.8 C (98.3 F), blood pressure is 160/98 mm Hg, pulse is 74/min, and respirations are 16/min. Neurologic examination shows mild short-term memory loss and decreased sensation to pinprick in the distal extremities. He has an ataxic gait. There are gouty tophi on the dorsal aspect of the left elbow. Laboratory studies show:

Which of the following is the most appropriate next step in management?

A
) Measurement of blood lead level

B
) Measurement of serum porphobilinogen level

C
) CT scan of the abdomen

D
) MRI of the brain

E
) Carbidopa-levodopa therapy

31. A county health officer investigates an outbreak of illness among persons attending a church picnic. The illness is characterized by the onset of nausea and vomiting 3 to 4 hours after attending the picnic. All affected persons recover without specific therapy. The investigation implicates egg salad as the vehicle of transmission. This episode is consistent with a foodborne outbreak caused by which of the following?

A
) Clostridium perfringens

B
) Giardia lamblia

C
) Salmonella species

D
) Staphylococcus aureus

32. A 62-year-old woman comes to the physician because of generalized weakness for 2 weeks. She has a 20-year history of arthritis of the hands treated with aspirin and acetaminophen. She had two episodes of urinary tract infections 5 and 11 years ago, respectively. Examination shows no abnormalities except for Heberden's nodes on the hands. Laboratory studies show:

33. A 60-year-old man comes to the physician because of increasing shortness of breath for 1 week; it occurs at rest and is exacerbated by exertion. He has not had chest pain. He has smoked two packs of cigarettes daily for 40 years. Between the ages of 18 and 30 years, he worked in a warehouse with exposed bare insulation; for the past 15 years, he has driven a taxi. Medications include ipratropium bromide and albuterol metered-dose inhalers. His temperature is 37 C (98.6 F), blood pressure is 170/95 mm Hg, pulse is 100/min, and respirations are 24/min. Anterior and posterior diffuse wheezes are heard. Cardiac examination shows no murmurs. There is mild pretibial edema. An x-ray film of the chest shows calcified pleural plaques on the right hemidiaphragm and a 2-cm pleural-based mass. With regard to the findings on the x-ray film, which of the following is most likely to have prevented this patient's condition?

A
) Appropriate immunizations

B
) Different occupation

C
) Different medications

D
) Hypertension screening

E
) Smoking cessation

34. A previously healthy 67-year-old man is admitted to the hospital because of lethargy, confusion, muscle cramps, and decreased appetite for 7 days. He appears ill. His temperature is 37 C (98.6 F), blood pressure is 120/70 mm Hg, pulse is 98/min, and respirations are 20/min. Breath sounds are diminished at the right lung base. Neurologic examination shows no abnormalities except for lethargy. Serum studies show:

An x-ray film of the chest shows a 2-cm nodule in the right lower lobe and mediastinal adenopathy. A biopsy specimen of the nodule is most likely to show which of the following?

A
) Adenocarcinoma

B
) Clear cell carcinoma

C
) Mesothelioma

D
) Small cell carcinoma

E
) Squamous cell carcinoma

35. A 62-year-old woman comes to the physician because of bloating and cramping abdominal pain and intermittent diarrhea over the past 5 years. Her symptoms have increased over the past month since she started a new diet that emphasizes yogurt and cottage cheese as low-fat sources of calcium and protein. Vital signs are within normal limits. Abdominal examination shows diffuse tenderness to palpation with no rebound tenderness; there are no masses or organomegaly. Bowel sounds are increased. Test of the stool for occult blood is negative. Which of the following is the best explanation for this patient's diarrhea?

A
) Impaired intestinal motility

B
) Inflammatory process

C
) Malabsorption

D
) Secretory process

36. A 52-year-old woman comes to the physician because of a 3-month history of intermittent bloody discharge from the right breast. She does not perform regular monthly breast self-examinations. She has a 3-year history of major depressive disorder treated with fluoxetine. Examination of the breasts shows no abnormalities. No masses are noted on palpation. Serosanguineous fluid can be expressed from the nipple of the right breast by pressing on the left side of the areola. Which of the following is the most likely diagnosis?

A
) Cystosarcoma phyllodes

B
) Fat necrosis

C
) Fibroadenoma

D
) Fibrocystic changes of the breast

E
) Galactorrhea

F
) Hyperprolactinemia

G
) Intraductal papilloma

H
) Mastitis

I
) Paget's disease of the breast

37. A 6-month-old girl is brought to the physician because of poor feeding and labored breathing for 2 months. She has had recurrent respiratory tract infections since birth. Examination shows a to-and-fro murmur in the second left intercostal space, a loud S2, bounding peripheral pulses, and a widened pulse pressure. Which of the following is the most likely diagnosis?

A
) Atrial septal defect (ostium primum type)

B
) Atrial septal defect (ostium secundum type)

C
) Atrioventricular canal

D
) Coarctation of the aorta

E
) Hypoplastic left heart syndrome

F
) Patent ductus arteriosus

G
) Tetralogy of Fallot

H
) Transposition of the great arteries

I
) Tricuspid atresia

J
) Ventricular septal defect

38. A 70-year-old man comes to the physician because of urinary hesitancy and frequency for 9 months. His temperature is 37.5 C (99.5 F). Examination shows a circumcised penis with no urethral discharge. Testicular examination shows no abnormalities. Rectal examination shows an enlarged rubbery prostate that is nontender to palpation. Urinalysis shows many leukocytes and no erythrocytes. Gram's stain of urine shows gram-negative rods. Which of the following is the most likely cause of this patient's condition?

A
) Infection of the epididymis

B
) Infection of the prostate

C
) Infection of the urethra

D
) Neurogenic bladder

E
) Outflow obstruction of the bladder

39. A 32-year-old woman comes to the physician because of lethargy and boredom since the birth of her son 5 months ago. She worries about her ability to care for him and has had frequent palpitations. She is unable to fall back asleep after nighttime feedings. She stopped breast-feeding 1 month ago. Her son is healthy, and growth and development are normal for his age. Her blood pressure is 122/80 mm Hg, pulse is 58/min, and respirations are 18/min. Physical examination shows no abnormalities. She remembers one out of three objects after 5 minutes. Her serum cholesterol level is 265 mg/dL. The most appropriate next step in diagnosis is measurement of which of the following serum levels?

A
) Cortisol

B
) Estrogen

C
) Progesterone

D
) Prolactin

E
) Thyroid-stimulating hormone

40. The genetic disease institute at a university hospital has developed a rapid screening test for a serious but treatable inherited metabolic disorder. Although this disorder is predominantly found in a particular ethnic group, it is also found sporadically throughout the entire population. The screening test has a sensitivity of 95% and a specificity of 90%. When used in an ethnically prescreened population where the prevalence of this disorder is 30%, the positive predictive value is 80% and the negative predictive value is 96%. The institute proposes to use this screening test on the general population where the prevalence of this disease is 0.1%. Which of the following is the most likely result of this screening program?

A
) Negative predictive value decreases

B
) Positive predictive value decreases

C
) Sensitivity decreases

D
) Specificity decreases

41. A 32-year-old woman comes to the physician because of a 1-year history of increasingly severe dull pain in her lower back and buttocks. She also has had morning stiffness of the lower back that lasts for 1 to 2 hours. There is no history of trauma. Her job does not require heavy lifting. Her blood pressure is 110/70 mm Hg, pulse is 68/min and regular, and respirations are 16/min. Cardiopulmonary examination shows no abnormalities. There is tenderness to palpation over the sacroiliac joints bilaterally and decreased flexion and extension of the lumbar spine. An x-ray film of the lumbosacral spine shows sclerosis of the sacroiliac joints. Laboratory studies are most likely to show which of the following findings in this patient?

A
) Decreased erythrocyte sedimentation rate

B
) Histocompatibility human leukocyte antigen B27

C
) Increased serum antinuclear antibody titer

D
) Increased serum carcinoembryonic antigen (CEA) level

E
) Positive serum rheumatoid factor

42. A 6-month-old boy is brought to the physician because of respiratory distress for 1 day. He had a persistent dry cough 3 days ago. He has not had a fever or nasal discharge, but he has had chronic watery stools. He is at the 50th percentile for height and 10th percentile for weight. He appears ill and is in respiratory distress. His temperature is 37 C (98.6 F), pulse is 140/min, and respirations are 78/min. Pulse oximetry shows an oxygen saturation of 70% while breathing room air. Examination shows white plaques on the mucous membranes of his mouth and diffuse adenopathy. There are intercostal retractions, and diffuse crackles are heard throughout all lung fields. In addition to oxygen and antibiotic therapy, which of the following is the most appropriate next step in management?

A
) Stool culture for bacterial pathogens

B
) Urinalysis

C
) HIV testing

D
) Quantitative measurement of immunoglobulins

E
) Nitroblue tetrazolium testing

F
) Platelet morphology evaluation

G
) Tympanocentesis

43. A 42-year-old man is brought to the physician by his wife because of a 2-month history of staring spells that last 1 to 2 minutes each. During episodes, he also smacks his lips and picks at his shirt collar. Four years ago, he was comatose for 2 weeks after sustaining a head injury in a motorcycle collision; he required 6 months of rehabilitation. He reports that, over the past year, he has had intermittent episodes of smelling burnt rubber that occur approximately every 2 weeks. He hears an intense hissing sound during these episodes. Examination shows no abnormalities. Which of the following is the most likely diagnosis?

A
) Absence seizures

B
) Complex partial seizures

C
) Transient ischemic attack

D
) Tourette's disorder

E
) Limbic encephalopathy

44.

A 47-year-old woman is admitted to the hospital for evaluation of a 2-week history of increased irritability and racing thoughts. Her family reports that she argues with anyone who does not agree with her. She has been talking incessantly at a rapid rate and pacing around the house. She says that, for years, she has been hearing the voice of God telling her that she has been chosen for a special mission. She has barely slept for the past week, waiting to hear further messages from God. She is disheveled and dehydrated. Serum studies show:

Mental status examination shows disorganized thoughts and flight of ideas. She is agitated and has difficulty staying seated. She is too distractible to perform cognitive tests. Toxicology screening is negative. Which of the following is the most likely diagnosis?

A
) Acute renal failure

B
) Borderline personality disorder

C
) Diabetes insipidus

D
) Narcissistic personality disorder

E
) Schizoaffective disorder

F
) Schizoid personality disorder

45. A 20-year-old man comes for a routine health maintenance examination. He has a 15-year history of difficulty relaxing his hands after tightly gripping objects or after shaking hands. His father has cataracts and frontal baldness. Examination shows thin forearms. There is moderate weakness of the hands and difficulty releasing after gripping with his hands. Which of the following is the most likely diagnosis?

A
) Amyotrophic lateral sclerosis

B
) Cervical spondylosis

C
) Multiple sclerosis

D
) Myasthenia gravis

E
) Myasthenic (Lambert-Eaton) syndrome

F
) Myotonic muscular dystrophy

G
) Polymyalgia rheumatica

H
) Polymyositis

I
) Progressive neuropathic (peroneal) muscular atrophy

46. A 47-year-old man is admitted to the hospital after threatening to harm a radio announcer he believed was broadcasting his thoughts. Over the past 20 years, he has had multiple psychiatric hospitalizations for threatening people who he believed were plotting against him, trying to control his mind, or causing him to hear voices by implanting devices in his head. Past symptoms improved with neuroleptic therapy; after discharge, he discontinued the medication and his symptoms worsened. Which of the following is the most appropriate pharmacotherapy to decrease this patient's risk for future hospitalization?

1.) A 50-year-old man with a 20-year history of type
2 diabetes mellitus has had sensory neuropathy for 2 weeks.
Pulses are decreased at the ankle. There is no peripheral edema. His serum
glucose levels have been between 150 mg/dL and 200 mg/dL over the past 6
months. Which of the following is the most effective measure to prevent
serious foot infections?

A) Use of support hose

B) Use of well-fitted shoes

C) Prophylactic antibiotics

D) Daily aspirin and dipyridamole

E) Decrease in serum glucose level

2.) A 63-year-old woman comes to the emergency
department because of palpitations for 1 hour. She was diagnosed with
hyperthyroidism 2 months ago but has not received treatment. Three
hours before arrival, she drank two bottles of beer with dinner. Her blood
pressure is 90/60 mm Hg, and pulse is 85/min and irregularly irregular.
Examination shows a variation in intensity of S1. There is an absence of
waves in the venous pulse. An ECG is shown. Which of the following is
the most likely cardiac rhythm disturbance?

A) Atrial fibrillation

B) Atrial flutter

C) Multifocal atrial tachycardia

D) Paroxysmal atrial tachycardia

E) Second-degree atrioventricular block, Wenckebach type

F) Sick sinus syndrome

G) Sinoatrial exit block, type II

H) Torsades de pointes

I) Wandering pacemaker

J) Wolff-Parkinson-White syndrome

3.) A 5-year-old girl is brought to the physician 30 minutes after
being bitten on the forearm by her cat. Examination shows a small
puncture wound covered with dried blood. She is at increased risk of
infection for which of the following reasons?

A) Arm wounds are more susceptible to infection

B) Salivary enzymes in cats augment infection

C) It is difficult to cleanse pathogens from this wound

D) The Staphylococcus species involved is particularly virulent

E) Young children are less able to resist infection than adults

4.) A 4-year-old girl is brought to the physician because of pallor
and jaundice for 2 days. She had previously been well, although she was
treated for jaundice with phototherapy for 2 weeks while a newborn.
Her mother and two additional maternal relatives underwent splenectomy
during childhood for unknown reasons. Examination of the patient shows
jaundice. The spleen tip is palpated 4 cm below the left costal margin.
Which of the following blood smear findings is most likely to explain this
family's condition ?

A) Elliptocytes

B) Howell-Jolly bodies

C) Schistocytes

D) Sickle cells

E) Spherocytes

5.) A sexually active 20-year-old woman has had fever, chills, malaise, and pain of the
vulva for 2 days. Examination shows a vulvar pustule that has ulcerated and
formed multiple satellite lesions. Nodes are palpated in the inguinal and
femoral areas. A smear of fluid from the lesions establishes the diagnosis.
Which of the following is the most likely causal organism?

A) Chlamydia trachomatis

B) Haemophilus ducreyi

C) Neisseria gonorrhoeae

D) Streptococcus pyogenes (group A)

E) Treponema pallidum

6.) A 5-year-old boy is brought to the physician 1 hour after
urinating bright red blood. He has been taking ibuprofen since injuring his
right flank while wrestling with friends yesterday; he also has been
taking penicillin for 3 days for streptococcal pharyngitis. His
temperature is 36.7 C (98 F), blood pressure is 90/48mm Hg, pulse is 108/min,
and respirations are 18/min. Examination shows purple ecchymoses over
the shins and right flank; there is tenderness of the right
costovertebral area. The abdomen is nontender. Genital examination shows no
abnormalities. There is no edema. Urinalysis shows gross blood;
microscopic examination shows 5–10 leukocytes/hpf and erythrocytes that
are too numerous to count. Which of the following is the most likely
explanation for this patient's hematuria?

A) Acute pyelonephritis

B) Ibuprofen-induced acute papillary necrosis

C) Post-streptococcal glomerulonephritis

D) Rhabdomyolysis

E) Traumatic injury to the kidney

7.) A 16-year-old girl comes to the physician for her first prenatal
visit at 12 weeks' gestation. She has not had any immunizations since
the age of 5 years. She has received the following immunizations at the
recommended ages:

Examination shows no abnormalities. Which of the following is the most
appropriate immunization to administer at this visit?

A) Diphtheria-tetanus-pertussis

B) Diphtheria (child)-tetanus toxoid

C) Diphtheria (adult)-tetanus toxoid

D) Haemophilus influenzae type b

E) Hepatitis B

F) Inactivated poliovirus

8.) A 12-year-old boy is brought to the physician because of
temperatures to 40.2 C (104.4 F), lethargy, and a stiff neck for 2 days. A
diagnosis of pneumococcal meningitis is made, and the child is admitted to
the hospital for antibiotic therapy. Serum studies 24 hours after
admission show:

Na+ 117 mEq/L
Cl– 89 mEq/L
HCO3– 25 mEq/L

Which of the following is the most likely explanation for these findings?

10.) A 26-year-old man has had anxiety and insomnia since he lost his
job 1 month ago. He also has had palpitations, daily headaches, and
flatulence. He has no history of psychiatric disorders. His mother has
a history of bipolar disorder, mixed, and his father has alcoholism;
his younger sister had a history of drug abuse but has been abstinent
from drugs for 3 years. Which of the following is the most likely
diagnosis?

12.) A 24-year-old third-year medical student comes to the student health clinic for
evaluation of jaundice which he noticed this morning. He has had no abdominal
pain, itching, or weight change. He takes no medications. He describes recent
anxiety over anticipation of the upcoming Step 2 examination. His temperature is
37 C (98.6 F), blood pressure is 120/80 mm Hg, pulse is 76/min, and respirations
are 12/min. Examination shows no abnormalities except for scleral icterus.

13.) A 37-year-old woman with a 2-year history of hypertension comes for a follow-up
examination; her hypertension has worsened despite treatment with a low-sodium
diet and a ß-adrenergic blocking agent. She has a history of rheumatic fever and
Graves' disease treated with 131I. Her blood pressure is 160/106 mm Hg, and
pulse is 80/min. Serum studies show:

Urinalysis is within normal limits. Renal ultrasonography shows a left kidney with a
markedly irregular contour; it is 2.8 cm smaller than the right.

A) Adrenal cortex

B) Adrenal medulla

C) Aorta

D) Renal arteries

E) Renal glomeruli

F) Thyroid gland

14.) A 27-year-old woman comes to the physician because of muscle weakness and
cramps for 2 weeks. She has been taking a ß-adrenergic blocking agent for
hypertension for 2 years. She had chronic lymphocytic thyroiditis (Hashimoto's
disease) 1 year ago. Her blood pressure is 160/108 mm Hg, and pulse is 60/min.
Serum studies show:

15.) A 24-year-old man is hospitalized for treatment of a posterior dislocation of the
right knee sustained in a motorcycle collision. Six hours after closed reduction,
previously present distal pulses in his foot are absent, but the foot has remained
warm. Which of the following is the most appropriate next step in management?

A) Elevation of the limb and observation for 24hours

B) Nitroprusside therapy

C) Sympathetic block

D) Femoral arteriography

E) Embolectomy with a Fogarty catheter through aproximal arteriotomy

D) Inflammation of the origin of the plantar fascia

16.) A healthy 4-year-old girl is brought for a well-child examination. A grade 2/6
systolic ejection murmur is heard along the upper left sternal border. S2 is widely
split and does not vary with respiration. A soft mid-diastolic murmur is heard along
the lower left sternal border. Examination shows no other abnormalities. Which of
the following is the most likely diagnosis?

A) Aortic stenosis

B) Atrial septal defect

C) Coarctation of the aorta

D) Mitral valve prolapse

E) Patent ductus arteriosus

F) Pulmonary stenosis

G) Tetralogy of Fallot

H) Transposition of the great arteries

I) Ventricular septal defect

J) Normal heart

18.) A previously healthy 57-year-old woman comes to the physician because of three
episodes of blurred vision in the right eye over the past 3 weeks; each episode
lasts approximately 5minutes. Retinal examination shows a small refractile body at
The bifurcation of a retinal artery. The remainder of the examination shows no
abnormalities. Which of the following is the most appropriate next step in
diagnosis?

A) Cerebral angiography

B) Echocardiography

C) Electroencephalography

D) Duplex scan of the carotid arteries

E) MRI of the brain

19.) A 67-year-old woman comes to the physician for her first influenza virus
vaccination. She has a history of untreated hypertension. Her blood pressure is
160/100 mm Hg, and pulse is 100/min. Shortly after administration of the
influenza virus vaccine, she develops shortness of breath, hives, and angioedema.
Which of the following is most likely to have prevented this reaction?

A) Inquiry about an egg allergy

B) Heterophile agglutination test

C) Skin test with histamine reagent

D) ß-Adrenergic blocking agent therapy

E) Amantadine therapy

F) Insulin therapy

G) Rimantadine therapy

20.) A 7-year-old girl is brought to the physician because of a 2-day history of fever,
headache, sore throat, and swollen glands. She does not have a runny nose,
congestion, or cough. She has no allergies to medications. Her temperature is
38.6C (101.4 F), blood pressure is 100/60 mm Hg, pulse is 120/min, and
respirations are 16/min. Examination shows a swollen, erythematous oropharynx
With tonsillar exudates. The anterior cervical lymph nodes are enlarged and
tender. No other abnormalities are noted. Which of the following is the most likely
causal organism?

A) Adenovirus

B) Corynebacterium diphtheriae

C) Group A streptococcus

D) Haemophilus influenzae

E) Mycoplasma pneumoniae

21.) A 70-year-old nursing home resident is admitted to the hospital because of
progressive obtundation over the past 2 days. He has tachycardia, tachypnea, and
hypotension. Bilateral basilar crackles and an S3 gallop are heard on auscultation.
Examination shows jugular venous distention and peripheral edema. Swan-Ganz
catheterization shows a cardiac index of 1.8 L/min/m2 (N=2.5–4.2), a mean
Pulmonary capillary wedge pressure of 23 mm Hg (N=1–10), and markedly
Increased systemic vascular resistance. Which of the following is the most likely
diagnosis?

A) Cardiogenic shock

B) Hypovolemic shock

C) Neurogenic shock

D) Septic shock

22.) A 42-year-old man with alcoholism is brought to the emergency department by a
friend because of fever and progressive shortness of breath for 12 hours. His
friend reports that they were eating leftover chicken and drinking beer earlier in
the day when the patient suddenly choked and vomited. Six hours later, he
developed sweating, chills, and shortness of breath. He has not had any
subsequent nausea, vomiting, hematemesis, or abdominal pain. He has smoked
Two packs of cigarettes daily for 22 years and drinks 12 to 18 beers daily. He is in
moderate respiratory distress. His temperature is 39.3 C (102.8 F), blood pressure
is 90/60 mm Hg, pulse is 120/min, and respirations are 24/min. Examination
shows no jugular venous distention. Breath sounds are decreased halfway up the
left lung with increased dullness. Cardiac examination shows a normal S1 and S2;
no murmurs are heard. There is no abdominal tenderness. Bowel sounds are
hypoactive. X-ray films of the chest show a left pleural effusion and air in the
mediastinum. Thoracentesis is performed.
Laboratory studies show:
Leukocyte count 18,000/mm3
Segmented neutrophils 85%
Bands 10%
Lymphocytes 5%
Serum Protein 6 g/dL
Lactate dehydrogenase 200 U/L
Pleural fluid Leukocyte count 8000/mm3
Segmented neutrophils 98%
Monocytes 2%
Protein 4.2 g/dL
Amylase 140 U/L
Lactate dehydrogenase 180 U/L
Gram's stain
WBC present
Organisms none

Which of the following is the most likely diagnosis?

A) Congestive heart failure

B) Esophageal rupture

C) Pancreatitis

D) Pericarditis

E) Tuberculosis

23.) A 2-year-old girl with tricuspid atresia has increasing respiratory distress for 2
days. She has been recovering uneventfully from an operation 10 days ago to join
systemic venous return with pulmonary arterial circulation. Over the past 4 days,
she has been weaned off mechanical ventilation, started on oral feedings, and
is receiving chest physiotherapy for atelectasis. Her temperature is 37.4 C (99.3 F),
blood pressure is 98/64 mm Hg, pulse is 120/min, and respirations are 46/min.
Examination shows nasal flaring, grunting, and intercostal retractions. An x-ray
film of the chest shows large bilateral pleural effusions. Thoracentesis yields 300
mL of whitish-yellow fluid. The supernatant remains uniformly opaque on
centrifugation. Which of the following is the most likely cause of the pleural
effusions?

A) Chylothorax

B) Congestive heart failure

C) Empyema

D) Pulmonary embolism

E) Superior vena cava obstruction

24.) A 23-year-old man is brought to the physician by his mother because he has heard
a voice over the past month telling him to hurt himself. His mother says that her
son has no friends and is a lifelong loner; since graduating from high school, he
has been unable to hold a job. He admits to smoking marijuana occasionally and
drinking six beers weekly. Examination shows a poorly groomed man with poor
eye contact. He has a flat affect and limited facial expression. He says he has no
intention of harming himself or others. Which of the following is the most
appropriate next step in management?

C) Admit him to the partial hospital program and prescribe oral lithium carbonate

D) Admit him to the psychiatric unit for detoxification

E) Admit him to the psychiatric unit and prescribe oral imipramine

25.) A 23-year-old man is brought to the physician by his mother because he has heard
a voice over the past month telling him to hurt himself. His mother says that her
son has no friends and is a lifelong loner; since graduating from high school, he
has been unable to hold a job. He admits to smoking marijuana occasionally and
Drinking six beers weekly. Examination shows a poorly groomed man with poor
Eye contact. He has a flat affect and limited facial expression. He says he
has no intention of harming himself or others. Which of the following is the most
appropriate next step in management?

C) Admit him to the partial hospital program and prescribe oral lithium carbonate

D) Admit him to the psychiatric unit for detoxification

E) Admit him to the psychiatric unit and prescribe oral imipramine

26.) An 18-month-old boy is brought for a well-child examination. He was born at 37
weeks' gestation and weighed 2800 g (6 lb 3oz). There were no prenatal or
perinatal complications. Developmental history indicates that he is able to run and
walk up stairs while holding his mother's hand. He can hold a crayon but does not
Scribble spontaneously. He is at the 40th percentile for length and 50th percentile
for weight. Examination shows a crude pincer grasp. Which of the following is the
most appropriate assessment of fine and gross motor development?

Fine Motor Gross Motor
Development Development

A) Delayed normal

B) Normal delayed

C) Delayed delayed

D) Normal normal

27.) Five months after beginning fluoxetine to treat obsessive-compulsive disorder, a
19-year-old man states that he discontinued his medication 2 months ago because
he had begun to worry about taking his medication every day. His initial response
to the medication was good. His symptoms have now returned, and his morning
ritual of cleaning and grooming consumes so much time that his job is in jeopardy.
In addition to education about the nature of his disorder and its treatment, which
of the following is the most appropriate next step in management?

A) Tell the patient to schedule a return visit as needed

B) Offer to change the medication

C) Request that the patient's parents superviseadministration of medication

D) Monitor the patient's compliance by weekly blood tests

E) Begin a trial of cognitive-behavior therapy

28.) A 32-year-old woman comes to the physician because of a 3-month history of
increasing pain and stiffness in her wrists, hands, and ankles. During this period,
she also has had progressive fatigue and morning stiffness lasting 2 hours. She has
a 1-year history of rheumatoid arthritis treated with naproxen. Examination shows
redness, swelling, and warmth over the wrist, hand, and ankle joints bilaterally.
There are nontender subcutaneous nodules over the extensor surfaces of both
elbows. X-ray films of the hands show diffuse osteopenia and erosions over several
of the distal metacarpal bones. Which of the following is the most appropriate
pharmacotherapy?

A) Add oral cyclophosphamide

B) Add oral gold

C) Add oral methotrexate

D) Add oral penicillamine

E ) Switch to oral ibuprofen

28.) A previously healthy 62-year-old man comes to the physician because of a 2-month
history of progressive shortness of breath and a mild nonproductive cough. He
does not smoke. He worked in a foundry most of his adult life before retiring 2
years ago. Vital signs are within normal limits. Crackles are heard at both lung
Bases with no wheezes. Cardiac examination shows an accentuated P2. The
remainder of the examination shows no abnormalities. An x-ray film of the chest
shows prominent interstitial markings at the lung bases. Echocardiography shows
an ejection fraction of 55%. Pulmonary function testing is most likely to show
which of the following?

A) Decreased FEV1:FVC ratio

B) Decreased maximal inspiratory effort

C) Decreased total lung capacity

D) Increased forced vital capacity

E) Normal carbon monoxide diffusion capacity

29.) A 55-year-old man is admitted to the hospital because of progressive shortness of
breath for 10 days. He has a history of chronic venous stasis and deep venous
thrombosis. He has been treated with warfarin since he had several pulmonary
emboli 2 years ago; he takes no other medication. He has smoked two packs of
Cigarettes daily for 30 years. He weighs 109 kg (240 lb) and is 165 cm (65 in) tall.
Examination shows jugular venous distention. Echocardiography is most likely to
show which of the following?

A) Left ventricular dilation

B) Mitral stenosis

C) Pericardial thickening and tamponade

D) Right ventricular hypertrophy and dilation

E) Tricuspid stenosis

30.) A 32-year-old woman comes to the physician because of weakness of the lower
extremities for 2 days. Three years ago, she had pain and partial loss of vision of
the right eye; the vision returned to normal after 6 weeks. There is mild pallor of
the right optic disc. She has impaired tandem gait. Babinski's sign is present
bilaterally. There is mild spasticity of the lower extremities and mild weakness of
the iliopsoas and hamstring muscles. Serum creatine kinase activity is 50 U/L.
Which of the following is the most likely diagnosis?

A) Amyotrophic lateral sclerosis

B) Becker's muscular dystrophy

C) Diffuse sensorimotor peripheral neuropathy

D) Duchenne's muscular dystrophy

E) Hyperkalemic periodic paralysis

F) Hypokalemic periodic paralysis

G) Multiple sclerosis

H) Myasthenia gravis

I) Myasthenic (Lambert-Eaton) syndrome

J) Myotonic muscular dystrophy

K) Polymyositis

L) Pontine astrocytoma

M) Pontine infarction

N) Spinal cord tumor

O) Transverse myelitis

31.) A healthy 42-year-old man comes to the physician for a life insurance evaluation.
He smoked one-half pack of cigarettes daily for 20 years but quit 10 years ago. His
father died of a myocardial infarction at the age of 65 years. The patient weighs 93
kg (205lb) and is 178 cm (70 in) tall. His blood pressure is 160/110 mm Hg,
pulse is 96/min, and respirations are 16/min. Physical examination, ECG, and an x-
ray film of the chest show no abnormalities. Laboratory studies are within normal
limits except for a serum cholesterol level of 206 mg/dL. Which of the following is
the greatest risk factor for cerebral infarction in this patient?

A) Genetic profile

B) History of smoking

C) Hypercholesterolemia

D) Hypertension

E) Obesity

32.) A previously healthy 56-year-old woman comes to the physician because of
jaundice and dark urine for 3 weeks. She has a 1-year history of generalized
pruritus. She takes no medications. Examination shows jaundice and several
ecchymoses over the forearms and thighs. The liver and spleen are enlarged and
nontender. Laboratory studies show:

Because of her condition, this patient is at greatest risk for which of the following
deficiencies?

A) Niacin

B) Vitamin A

C) Vitamin B2 (riboflavin)

D) Vitamin B12 (cyanocobalamin)

E) Vitamin C

33.) An asymptomatic 52-year-old man comes for a
follow-up
examination 1 month after he passed renal calculi. He
has a history of renal
calculi 2 years ago. Serum uric acid and calcium
levels and urinary
oxalate excretion are within normal limits. Urinary
calcium excretion is
increased. In order to avoid recurrence of renal
calculi, which of the
following is the most appropriate pharmacotherapy for
this patient?

A
) Bicarbonate

B
) Calcium lactate

C
) Methenamine mandelate

D
) Probenecid

E
) Thiazide diuretic

34.

A 57-year-old woman is brought to the emergency
department because of
abdominal pain for 12 hours. Over the past 3 hours,
the pain has become
severe and generalized. Over the past month, she has
had mild upper
abdominal discomfort that is relieved by eating. She
has a history of
recurrent migraines treated with sumatriptan as
needed. Her temperature
is 38.2 C (100.8 F), blood pressure is 170/95 mm Hg,
and pulse is
110/min. Abdominal examination shows mild distention;
there is marked
rigidity with diffuse tenderness. Bowel sounds are
absent. Rectal
examination shows no abnormalities; test of the stool
for occult blood is
negative. Laboratory studies show:

Which of the following is the most appropriate next
step in diagnosis?

A
) X-ray films of the abdomen while supine and
standing

B
) Abdominal ultrasonography

C
) Upper gastrointestinal series with contrast

D
) HIDA scan

E
) Fiberoptic endoscopy of the upper
gastrointestinal tract

35. An 18-year-old man comes to the physician
because of itchy
lesions on his penis for 2 weeks and itching around
his wrists and ankles
for 1 week. He is sexually active and does not
consistently use condoms.
Examination shows scattered, crusted lesions on the
penis and no
significant inguinal lymphadenopathy. There are
excoriated papules on the
wrists and ankles, a few papules between the fingers,
and excoriations
along the belt line. Which of the following is the
most likely
diagnosis?

A
) Disseminated primary herpes simplex

B
) Eczema

C
) Scabies

D
) Secondary syphilis

E
) Vasculitis

36. An asymptomatic 62-year-old man comes for a
follow-up visit.
One month ago, he had acute cystitis treated with
ciprofloxacin. At his
initial visit, a urine culture grew Klebsiella
pneumoniae. He has a
2-year history of chronic prostatitis and has had four
episodes of
cystitis over the past year. His temperature is 36.9
C (98.4 F).
Examination, including prostate examination, shows no
abnormalities. Which of
the following is the most appropriate measure to
prevent recurrent
episodes of cystitis in this patient?

A
) Trimethoprim-sulfamethoxazole prophylaxis

B
) Insertion of a Foley catheter

C
) Total prostatectomy

D
) Transurethral prostatectomy

E
) No treatment is available

37. A 32-year-old woman comes for a routine health
maintenance
examination. Examination shows a bloody discharge
from the nipple of her
left breast. There is no palpable mass. On
questioning, she says that
she never noted the discharge and does not perform
breast
self-examinations. Which of the following is the most
likely diagnosis?

A
) Breast abscess

B
) Breast cyst

C
) Breast hematoma

D
) Fibroadenoma

E
) Fibrocystic changes of the breast

F
) Intraductal adenoma

38. A 35-year-old woman is brought to the physician
by her husband
because of increasing memory loss and involuntary
"dancing" movements
over the past 6 weeks. She has had difficulty
remembering things,
particularly recent events. She has had no
disturbances in sleep or appetite.
Her medical history is unremarkable. She does not
remember her mother
who died 25 years ago, but her father told her that
her mother had
similar symptoms several years before her death.
Neurologic examination
shows involuntary choreiform movements. She has a
childlike affect. She
describes her mood as good. On recall testing, she
can remember one out
of three objects after 3 minutes with distraction; she
cannot remember
the other objects with prompting. She cannot remember
the date of her
marriage or her previous address. The most likely
cause of these
symptoms is a lesion at which of the following
locations?

A
) Caudate nucleus

B
) Parietal lobe

C
) Prefrontal lobe

D
) Putamen

E
) Temporal lobe

39. A 67-year-old man comes to the physician
because of insomnia for
2 years. He goes to bed at 11:00 PM after taking a
bath but does not
fall asleep until midnight. He usually wakes up twice
each night: once
around 3:00 AM to void and again at 6:00 AM. He stays
in bed until his
alarm goes off at 7 AM. He is concerned because he
used to sleep 8
hours daily. He recently retired from his job as an
attorney. He takes
no medications. He drinks one beer with lunch 3 days
each week and one
glass of wine with dinner each evening. He walks 1
mile daily after
dinner. Physical examination shows no abnormalities.
His mood is
neutral, and cognition is intact. Urine toxicology
screening is negative.
Which of the following is the most likely cause of
this patient's
symptoms?

A
) Advanced sleep phase syndrome

B
) Alcohol abuse

C
) Delayed sleep phase syndrome

D
) Major depressive disorder

E
) Melatonin deficiency

F
) Poor sleep hygiene

G
) Normal aging

40. An asymptomatic 37-year-old woman comes for a
follow-up
examination 1 year after receiving a renal transplant.
Current medications
include felodipine, enalapril, cyclosporine,
pravastatin, and penicillin
G. She appears well. Her temperature is 36.8 C (98.2
F), blood
pressure is 160/95 mm Hg, pulse is 80/min, and
respirations are 12/min.
Examination shows no other abnormalities. Which of
the following
medications is the most likely cause of this patient's
hypertension?

A
) Cyclosporine

B
) Enalapril

C
) Felodipine

D
) Penicillin G

E
) Pravastatin

41. A 4080-g (9-lb) male newborn is delivered at
term to a
32-year-old woman, gravida 2, para 1. Apgar scores
are 8 and 9 at 1 and 5
minutes, respectively. Examination in the delivery
room shows fracture of
the right clavicle. Which of the following is the
most likely sequela
of this condition?

A
) Correction only with casting

B
) Correction only with physical therapy

C
) Left-hand dominance

D
) Permanent nerve damage

E
) Spontaneous healing without treatment

42. A 22-year-old man with schizoaffective disorder
is brought to
the emergency department 2 hours after the sudden
onset of neck and back
pain. The symptoms began after taking one of his
medications for his
psychiatric disorder. The dosage was increased
yesterday, but he does
not recall the names of either of his medications. He
has no other
history of serious illness. Physical examination
shows rigid contraction
of the neck and back muscles with arching. On mental
status
examination, he is alert and cooperative and hears a
faint voice that tells him to
wash windows. He is oriented to person, place, and
time. Which of the
following medications is most likely responsible for
this patient's
symptoms?

A
) Clozapine

B
) Haloperidol

C
) Lithium carbonate

D
) Trazodone

E
) Valproic acid

43. A 52-year-old woman, gravida 3, para 3, comes
to the physician
because of irregular vaginal bleeding over the past 2
months. She has
hypertension treated with enalapril and type 2
diabetes mellitus well
controlled with diet. Menopause occurred 2 years ago.
Her maternal aunt
had breast cancer at the age of 70 years. The patient
weighs 88 kg
(195 lb) and is 160 cm (63 in) tall. Examination
shows no other
abnormalities. An endometrial biopsy specimen shows
adenocarcinoma. Which of
the following is the most significant predisposing
factor for this
patient's endometrial cancer?

A
) Heredity

B
) Hypertension

C
) Parity

D
) Type 2 diabetes mellitus

E
) Weight

44. A 67-year-old man is brought to the emergency
department 2 hours
after the onset of weakness and double vision. He has
hypertension and
hyperlipidemia treated with metoprolol, captopril, and
atorvastatin.
His blood pressure is 190/106 mm Hg. Neurologic
examination shows
left-sided facial weakness including the forehead.
There is palsy of left
conjugate gaze, and the left eye fails to adduct on
right gaze.
Vertical eye movements are intact. Muscle strength is
3/5 in the right upper
and lower extremities. Deep tendon reflexes are
brisk, and Babinski's
sign is present on the right. Which of the following
is the most
likely location of this patient's lesion?

A
) Bilateral thalamic

B
) Left frontal

C
) Left pontine

D
) Right caudate

E
) Right midbrain

45. Six weeks after spontaneous drainage of an anal
abscess, a
32-year-old man has persistent blood-stained purulent
fluid on his
underwear. He has not had significant anal pain since
drainage of the boil.
Bowel movements are normal. Which of the following is
the most likely
diagnosis?

A
) Anal fissure

B
) Fistula in ano

C
) Pruritus ani

D
) Thrombosed external hemorrhoids

E
) Thrombosed internal hemorrhoids

46. A previously healthy 14-year-old girl is
brought to the
physician because of a 2-day history of fever and pain
and swelling of the
right knee. She remembers injuring the knee while
playing soccer last
week, but she was able to finish the game. She has no
history of rash or
joint pain. Her sister has inflammatory bowel
disease. The patient's
temperature is 39 C (102.2 F), blood pressure is
110/80 mm Hg, pulse is
95/min, and respirations are 20/min. Examination of
the right knee
shows swelling, tenderness, warmth, and erythema;
range of motion is
limited. Which of the following is the most
appropriate next step in
management?

A
) X-ray film of the right knee

B
) Gastrointestinal series with small-bowel

follow-through

C
) Nuclear scan of the right knee

D
) MRI of the right knee

E
) Antibiotic therapy

F
) Arthrocentesis

block 2

dolly123 - 11/07/06 17:58 #548028

1.

A 25-year-old man is brought to the emergency
department after being
discovered semiconscious and incoherent at home. On
arrival, he is
stuporous. His blood pressure is 105/70 mm Hg, pulse
is 80/min, and
respirations are 12/min. Examination shows cool, damp
skin. The pupils are
pinpoint and react sluggishly to light. Which of the
following is the
most likely substance taken?

A
) Alcohol

B
) Barbiturates

C
) Cocaine

D
) Heroin

E
) LSD

2. A 15-year-old girl is brought to the emergency
department by her
20-year-old sister because of a 1-week history of
fatigue, nausea, and
abdominal pain. Menarche was at the age of 12 years,
and her last
menstrual period was 3 weeks ago. She has not had
vaginal discharge. She
is sexually active, and she and her partner use
condoms inconsistently.
Her temperature is 37 C (98.6 F), blood pressure is
110/60 mm Hg, and
pulse is 95/min. Abdominal examination shows mild
bilateral lower
quadrant tenderness. Before a pelvic examination and
a pregnancy test can
be performed in this patient, consent must be obtained
from which of the
following?

A
) The court

B
) The patient

C
) The patient's parent

D
) The patient's sister

E
) No consent is necessary

3. A previously healthy 57-year-old man comes to
the physician
because of a nonpruritic rash over both legs for 1
week and a low-grade
fever for 2 days. He recently returned from a 2-week
canoe trip on a river
in Minnesota. His temperature is 37.2 C (99 F).
Examination shows a 4
x 6-cm, macular, dark pink, ovoid lesion on the right
posterior hip
with central clearing and a punctate eschar near the
center. There are
macular ring lesions with central clearing over the
medial tibia and
anterior thighs of the lower extremities. He has no
lymphadenopathy.
Which of the following is the most likely causal
organism?

A
) Borrelia burgdorferi

B
) Brucella melitensis

C
) Francisella tularensis

D
) Leptospira interrogans

E
) Rickettsia rickettsii

4. A 57-year-old woman comes to the physician
because of a 2-year
history of increasing menstrual flow. She has not had
hot flashes,
insomnia, or change in bowel or bladder function. Her
last menstrual period
was 2 weeks ago. Pelvic examination shows a
normal-appearing vulva,
vagina, and cervix. The uterus is consistent in size
with an 8-week
gestation. Bimanual examination shows a 4-cm, firm,
nontender left ovary. An
endometrial biopsy specimen shows atypical complex
endometrial
hyperplasia. Which of the following is the most likely
cause of this patient's
hyperplasia?

A
) Adrenal adenoma

B
) Brenner tumor

C
) Carcinoid tumor

D
) Granulosa cell tumor

E
) Hyperthecosis

F
) Islet cell tumor

G
) Sertoli-Leydig cell tumor

5. A 67-year-old woman comes to the physician
because of vaginal
bleeding for 10 days. She has been soaking one
sanitary pad daily.
Menopause was 10 years ago. Her last Pap smear 5
years ago showed normal
findings. Her temperature is 37 C (98.6 F), blood
pressure is 128/78 mm
Hg, pulse is 70/min, and respirations are 12/min.
Pelvic examination
shows a normal-appearing cervix and a small amount of
blood at the
cervical os. There is moderate thinning of the
vaginal mucosa. The uterus
is irregular and consistent in size with a 10-week
gestation. There
are no adnexal masses. Rectovaginal examination shows
no abnormalities.
Test of the stool for occult blood is negative. Which
of the following
is the most appropriate next step in diagnosis?

A
) Transvaginal ultrasonography of the pelvis

B
) Colposcopic-guided biopsy

C
) Endometrial biopsy

D
) Endometrial ablation

E
) Culdocentesis

6. During a routine examination, a 32-year-old man
has a blood
pressure of 120/80 mm Hg. He is concerned because his
father, grandfather,
and two uncles have hypertension. He works as a
systems programmer for
a large computer company and frequently has to meet
tight deadlines.
He has smoked one pack of cigarettes daily for 10
years. He is 4.5 kg
(10 lb) overweight and drinks three cups of coffee
daily. Which of the
following measures is most likely to reduce this
patient's risk for
hypertension over the next 5 years?

A
) Increase intake of dietary fiber

B
) Restrict caffeine

C
) Stress management

D
) Weight loss

7. A previously healthy 16-year-old boy comes to
the physician
because of persistent pain in his left testicle for 24
hours. He has not
had any penile discharge. There is no history of
trauma, but he plays
soccer every day. Two months ago, he had sexual
intercourse for the
first time, and he used a condom. Examination shows
an edematous,
erythematous, exquisitely tender left scrotum that is
lower than the right.
Elevating the left testicle relieves the pain. The
cremasteric reflex is
present. Urinalysis shows 10 leukocytes/hpf and 1+
leukocyte esterase.
A technetium 99m scan shows increased uptake in the
left testicle.
Which of the following is the most likely cause of the
pain?

A
) Cystitis

B
) Epididymitis

C
) Spermatocele

D
) Testicular torsion

E
) Testicular tumor

8. A 47-year-old woman comes to the physician
because of persistent
nonproductive cough for 6 weeks. She has not had
fever or weight loss.
She has hypertension treated with enalapril for the
past 3 months. She
does not smoke. There is no history of lung disease.
She weighs 54 kg
(120 lb) and is 163 cm (64 in) tall. Her temperature
is 37 C (98.6 F),
blood pressure is 130/80 mm Hg, pulse is 70/min, and
respirations are
12/min. Examination and an x-ray film of the chest
show no
abnormalities. Which of the following is the most
likely mechanism of this
patient's cough?

A
) Decreased plasma renin activity

B
) Decreased serum angiotensin II levels

C
) Increased serum angiotensin I levels

D
) Increased serum bradykinin levels

E
) Increased serum histamine levels

9. A 57-year-old man has been hospitalized for 2
days for treatment
of unstable angina pectoris. He is currently
receiving intravenous
heparin and undergoing evaluation for coronary artery
bypass grafting.
His blood pressure is 160/90 mm Hg, pulse is 88/min,
and respirations are
16/min. Laboratory studies show:

10. A study is conducted to assess the
effectiveness of a new blood
test for early detection of prostate cancer. Ten
thousand healthy men
over the age of 50 years are randomly assigned to
receive either annual
rectal examination or annual screening with the new
blood test. After
5 years, results show that of the 50 men in the blood
test group that
were diagnosed with prostate cancer, 40 were living 2
years after the
diagnosis was made. In comparison, only 15 out of 45
men in the rectal
examination group survived 2 years after being
diagnosed with prostate
cancer. Researchers conclude that the blood test
increases survival
compared with rectal examination. Which of the
following potential flaws
is most likely to invalidate this conclusion?

A
) Age of the patients

B
) Diagnostic bias

C
) Lead time bias

D
) Recall bias

E
) Type II error

11.

A 62-year-old man comes to the emergency department
because of
progressive shortness of breath for 3 days. He has
not had chest pain,
orthopnea, or paroxysmal nocturnal dyspnea. He
completed chemotherapy for
small cell carcinoma of the lung 10 months ago. He
has a history of twice
nightly nocturia that has resolved over the past 3
days. He smoked two
packs of cigarettes daily for 30 years but quit 1 year
ago. His blood
pressure is 96/60 mm Hg, and pulse is 116/min. There
is jugular venous
distention to the angle of the jaw. The lungs are
clear to
auscultation. Cardiac examination shows distant heart
sounds, an S1 and S2, and no
gallops or rubs. The liver has a span of 12 cm and is
tender. There
is no pedal edema. Laboratory studies show:

An ECG shows diminished amplitude of the QRS
complexes. An x-ray film
of the chest shows clear lung fields with an enlarged
cardiac
silhouette. Which of the following findings is most
likely to be accentuated?

A
) Cardiac output

B
) Fall in systolic arterial pressure with
inspiration

C
) Left ventricular end-diastolic pressure

D
) Mitral regurgitation

E
) Ventricular septal wall motion

12. A 35-year-old woman comes to the physician
because of two
12-hour episodes of dizziness over the past 3 months.
During episodes, she
experiences the acute onset of rotatory vertigo and
imbalance, decreased
hearing, tinnitus, a sense of fullness of the right
ear, and vomiting.
Examination shows a mild hearing loss of the right
ear. Which of the
following is the most likely diagnosis?

A
) Acoustic neuroma

B
) Benign positional vertigo

C
) Brain stem transient ischemic attacks

D
) Meniere's disease

E
) Viral labyrinthitis

3. An obese 33-year-old woman has had four 12-hour
episodes of
severe, sharp, penetrating pain in the right upper
quadrant of the abdomen
associated with vomiting but no fever. She has no
diarrhea, dysuria, or
jaundice and is asymptomatic between episodes. There
is slight
tenderness to deep palpation in the right upper
quadrant. Which of the
following is the most appropriate next step in
diagnosis?

A
) Supine and erect x-ray films of the abdomen

B
) Upper gastrointestinal series

C
) Ultrasonography of the upper abdomen

D
) CT scan of the abdomen

E
) HIDA scan of the biliary tract

14. An otherwise healthy 19-year-old woman comes to
the physician
because of a 3-year history of intermittent facial
blemishes. She drinks
wine occasionally on weekends. She takes no
medications. Examination
shows multiple 1- to 2-mm red and white papules and
larger red nodules
on the forehead and cheeks. Which of the following is
the most
appropriate initial pharmacotherapy?

A
) Oral isotretinoin

B
) Systemic corticosteroids

C
) Topical benzoyl peroxide

D
) Topical corticosteroids

E
) Topical metronidazole

15. A previously healthy 67-year-old man comes to
the physician
because of a 4-month history of hand weakness,
intermittent tingling of the
small fingers of his hands, and mild neck pain.
Examination shows
wasting, weakness, and fasciculations of the
interossei muscles. Sensation
is decreased to pinprick and vibration in the small
fingers of each
hand. Triceps tendon reflexes are decreased. Which
of the following is
the most likely diagnosis?

A
) Amyotrophic lateral sclerosis

B
) Cervical spondylosis

C
) Multiple sclerosis

D
) Myasthenia gravis

E
) Myasthenic (Lambert-Eaton) syndrome

F
) Myotonic muscular dystrophy

G
) Polymyalgia rheumatica

H
) Polymyositis

I
) Progressive neuropathic (peroneal) muscular

atrophY

16. A 19-year-old college student comes to student
health services
because of constant worrying since starting his
freshman year 6 months
ago. He attends college several hundred miles away
from his hometown.
He reports feeling constantly scrutinized by other
students and
professors. He feels embarrassed and anxious in class
and is in constant fear
of blushing. He has started to skip his classes
because of his anxiety
and worries that he will not be able to complete the
school year. He
drinks alcohol occasionally because it helps him
overcome his fear of
being embarrassed in front of others. He does not use
illicit drugs.
Physical examination shows no abnormalities. On
mental status
examination, he is mildly anxious. He exhibits fair
eye contact and shifts
uncomfortably in his chair. Laboratory studies are
within normal limits.
Which of the following is the most appropriate
pharmacotherapy for this
patient?

A
) Disulfiram

B
) Donepezil

C
) Fluoxetine

D
) Haloperidol

E
) Methylphenidate

F
) Valproic acid

17.

A 42-year-old woman comes for a follow-up examination.
Two weeks ago,
her blood pressure was 152/94 mm Hg during a routine
visit. Her blood
pressure today is 150/94 mm Hg, pulse is 76/min, and
respirations are
14/min. Examination shows no other abnormalities.
Serum studies show:

An ECG shows no abnormalities. Which of the following
is the most
appropriate next step in management?

A
) Measurement of plasma renin activity

B
) Serum lipid studies

C
) 24-Hour urine collection for measurement of
metanephrine level

D
) Echocardiography

E
) Captopril renal scan

18. A 6-year-old boy with cystic fibrosis is
brought to the
physician by his mother because his skin has been cool
and clammy for 30
minutes. Earlier in the day, he had been playing
outdoors, and the
temperature was 99 F. When returning indoors, he was
thirsty and restless. His
blood pressure is 70/40 mm Hg, and pulse is 120/min.
Examination shows
dry mucous membranes. Serum sodium level is 128
mEq/L, and serum
chloride level is 87 mEq/L. Which of the following is
the most likely
explanation for these findings?

A
) Excessive sweat electrolyte level

B
) Excessive sweat volume

C
) Excessive urinary output

D
) Excessive vasopressor secretion

E
) Inadequate sweat production

19.

A 27-year-old primigravid woman at 29 weeks' gestation
comes to the
emergency department because of a 24-hour history of
increasingly severe
right-sided abdominal pain and no appetite. She has
vomited twice over
the past 4 hours. She has not had vaginal bleeding.
Her temperature
is 38.2 C (100.8 F). Examination shows exquisite
tenderness of the
right lateral flank and the fundus. There are no
peritoneal signs. Bowel
sounds are absent. The fetal heart rate is 144/min.
Laboratory
studies show:

20. A 32-year-old woman has had a lump in her neck
for 6 months.
She has a 1.2-cm solitary left thyroid nodule.
Fine-needle aspiration
cytology of the mass is consistent with a low-grade
papillary malignancy.
Which of the following is the most appropriate next
step in management?

A
) Thyroid scan

B
) 131I therapy

C
) Propylthiouracil therapy

D
) Thyroxine therapy

E
) Left thyroid lobectomy

For each patient with vaginal bleeding, select the
most likely
diagnosis.

A
) Bacterial vaginosis

B
) Precocious puberty

C
) Urinary tract infection

D
) Vaginal foreign body

E
) Vaginal laceration

F
) von Willebrand's disease

21. A 12-year-old girl is brought to the physician
by her mother
because of heavy vaginal bleeding since her first
menstrual period began 1
week ago. She has to change sanitary pads every 2
hours, and her
mother is concerned that this is not normal. Her
blood pressure is 80/60 mm
Hg, and pulse is 110/min. Breast and axillary and
pubic hair
development are Tanner stage 4. Pelvic examination
shows normal external
genitalia, a small normal-appearing cervix, and a
small uterus. Her
hemoglobin level is 7 g/dL.

22. A 7-year-old girl is brought to the physician
by her mother 4
hours after she noticed that her daughter had blood on
her underwear.
She has no signs of sexual development. Examination
shows normal
external genitalia. There is a foul-smelling
discharge.

23.

A 10-year-old girl is brought to the physician because
of temperatures
to 40 C (104 F) and headaches for 1 week. Her mother
says that fever
and chills occur every other day and typically last
for several hours.
She appears ill and is lethargic during febrile
episodes. She and her
family returned from a trip to West Africa 2 weeks
ago. She currently
appears ill. Her temperature is 40 C (104 F), blood
pressure is 94/64
mm Hg, pulse is 146/min, and respirations are 20/min.
Examination shows
mild scleral icterus and conjunctival pallor. The
liver edge is
palpated 3 cm below the right costal margin, and the
spleen tip is palpated 3
cm below the left costal margin. Laboratory studies
show:

Which of the following measures is most likely to have
prevented this
condition?

A
) Hepatitis A vaccine

B
) Typhoid vaccine

C
) Oral isoniazid prophylaxis

D
) Oral mefloquine prophylaxis

E
) Oral trimethoprim-sulfamethoxazole prophylaxis

F
) Intramuscular immune globulin

24. A 6-month-old boy is brought to the physician
because of
seizures over the past week. His parents note that
during this period, he has
had 10 to 20 episodes of throwing out his arms for 1
to 2 seconds then
crying as if he were afraid of something. He was born
at term
following an uncomplicated pregnancy and delivery.
Development is appropriate
for age. Two days ago, treatment with amoxicillin was
begun for otitis
media. He appears pale and apathetic. Examination
shows multiple
white patches over the skin that become more distinct
with Wood's lamp
examination. Neurologic examination shows no
abnormalities. An MRI of the
brain is shown. Which of the following is the most
likely diagnosis?

A
) Congenital cytomegalovirus encephalopathy

B
) Congenital toxoplasmosis encephalopathy

C
) Hypoxic-ischemic encephalopathy

D
) Neurofibromatosis

E
) Tuberous sclerosis

25.

An ELISA is used to detect Chlamydia trachomatis
infection in patients
seen at a family planning clinic. In the first 500
patients, cultures
are also done to check the accuracy of the ELISA. The
results are
listed below:

Chlamydia culture
+

-

ELISA
+

38
5
-

2

455

Which of the following is the positive predictive
value of the ELISA?

A
) 2/40

B
) 5/43

C
) 38/40

D
) 38/43

E
) 38/493

26. A 27-year-old woman is brought to the emergency
department by
her mother who found her comatose 30 minutes ago. Her
mother says that
her daughter had been having lower abdominal pain and
vaginal bleeding
over the past week. The patient had an ectopic
pregnancy 2 years ago
and was also treated with doxycycline for pelvic
inflammatory disease at
that time. Her blood pressure is 40/20 mm Hg, pulse
is 160/min, and
respirations are 24/min. The abdomen is distended and
rigid with
decreased bowel sounds. Hemoglobin level is 4.2 g/dL,
and leukocyte count is
12,500/mm3. Culdocentesis is positive. Which of the
following is the
most appropriate next step in management?

A
) Bromocriptine therapy

B
) Clomiphene therapy

C
) Conjugated estrogen therapy

D
) Ergot derivative therapy

E
) Hysteroscopy

F
) Laparoscopy

G
) Dilatation and curettage

H
) Endometrial ablation

I
) Exploratory laparotomy

J
) Total abdominal hysterectomy

27. A 43-year-old man comes to the emergency
department because of
fever, chills, malaise, cough, and pleuritic chest
pain for 3 days; the
cough is productive of foul-smelling, purulent sputum.
He has
alcoholism. His temperature is 39.2 C (102.6 F),
blood pressure is 110/70 mm
Hg, pulse is 120/min, and respirations are 14/min.
Hemoglobin level is
15 g/dL, and leukocyte count is 25,000/mm3. An ECG
shows normal
findings. An x-ray film of the chest shows a 4-cm
cavity in the superior
segment of the right lower lobe and an air-fluid
level. While awaiting
results of sputum culture, which of the following is
the most appropriate
next step in management?

A
) Observation

B
) Broad-spectrum antibiotic therapy

C
) Isoniazid therapy

D
) Intravenous amphotericin B therapy

E
) Tube thoracostomy

28.

A 12-year-old girl with type 1 diabetes mellitus is
brought to the
physician because of shortness of breath and fatigue
for 1 day. Since
menarche began 4 months ago, she has had one episode
of diabetic
ketoacidosis per month; prior to that she had been
stable. Her blood pressure is
110/70 mm Hg, pulse is 140/min, and respirations are
36/min. She
appears to be moderately dehydrated. Laboratory
studies show:

Which of the following is the most likely underlying
cause of this
patient's respiratory disorder?

A
) Acute interstitial nephritis

B
) Acute renal failure

C
) Diabetic nephropathy

D
) Hyperinsulinemia

E
) Increased plasma ketone level

29. A 28-year-old woman develops fatigue and
orthopnea 3 weeks after
the uncomplicated delivery of her first child. Her
blood pressure is
115/78 mm Hg, and pulse is 112/min. Crackles are
heard at both lung
bases. The point of maximal impulse is laterally
displaced and diffuse;
an S3 is present. There is 2+ pedal edema. An x-ray
film of the chest
shows vascular cephalization of pulmonary vasculature
and Kerley B lines.
Which of the following is the most appropriate next
step in management?

30. A previously healthy 22-year-old woman comes to
the physician
because of a paroxysmal cough for 2 weeks. She works
as an oncology
nurse. Her temperature is 37 C (98.6 F). Examination
shows no
abnormalities except for intermittent coughing spells
during the examination. An
x-ray film of the chest is normal. Cultures of
nasopharyngeal
secretions grow Bordetella pertussis. Which of the
following is the most
appropriate pharmacotherapy for this patient?

A
) Amoxicillin

B
) Amoxicillin-clavulanate

C
) Cefprozil

D
) Erythromycin

E
) Penicillin G

31. A 5-year-old girl is brought to the physician
because of a 2-day
history of temperatures to 39.5 C (103.1 F) and pain
in the right side.
She has had two episodes of vomiting during this
period but no diarrhea
or symptoms of upper respiratory tract infection. She
has
vesicoureteral reflux and a history of recurrent
urinary tract infections. She
appears ill. Her temperature is 39.8 C (103.6 F),
blood pressure is
110/60 mm Hg, pulse is 150/min, and respirations are
25/min. Examination
shows right-sided costovertebral angle tenderness. In
addition to
obtaining urine cultures, which of the following is
the most appropriate next
step in management?

A
) Intravenous pyelography

B
) Renal ultrasonography

C
) Voiding cystourethrography

D
) Intramuscular antibiotic therapy and
reexamination in 24 hours

E
) Intravenous antibiotic therapy

32. A 10-year-old boy is brought to the physician
because of
weakness and decreased appetite for 3 months. He
weighs 30 kg (66 lb) and is
142 cm (56 in) tall; he has had a 2.3-kg (5-lb) weight
loss since his
last examination 6 months ago. He appears thin. Deep
tendon reflexes
are brisk. Chvostek's sign is positive. His serum
calcium level is 6.5
mg/dL, and serum intact parathyroid hormone level is
190 pg/mL
(N=9–65). In addition to calcium supplementation,
which of the following is
the most appropriate next step in management?

A
) Oral phosphate supplementation

B
) Oral vitamin D supplementation

C
) Intranasal calcitonin therapy

D
) Parenteral bisphosphate therapy

E
) Parenteral parathyroid hormone therapy

33. A healthy 8-year-old girl is brought to the
physician in July
for a well-child examination. Her mother says that
her daughter is
spending the summer at a nearby lake. Over the past
month, she has had two
episodes of painful sunburn despite her mother's
efforts, including SPF
25 sunblock just before she goes swimming and urging
her to wear a hat
and long-sleeved garments. The child takes no
medications. She has
blond hair, blue eyes, and a fair complexion. The
mother seeks advice
about preventing further sun damage to her child's
skin. Which of the
following is the most appropriate recommendation?

A
) Prohibit swimming on cloudless days

B
) Apply the sunblock lotion 45 minutes before
swimming

C
) Change to a higher-level SPF lotion

D
) Apply Burrow's solution compresses after each
overexposure

E
) Daily use of antioxidant vitamin supplement

F
) Early treatment of any sun overexposure with
topical
corticosteroids

34. Two days after admission to the hospital
because of a 3-day
history of slurred speech, double vision, and
dysphagia, a 24-year-old
woman becomes quadriplegic and requires intubation and
mechanical
ventilation. Her medical history is unremarkable.
One week ago, she attended a
family picnic; several of her family members have had
abdominal cramps
and diarrhea since the picnic. Her temperature is 37
C (98.6 F), blood
pressure is 120/80 mm Hg, and pulse is 120/min.
Examination shows dry
mucous membranes, large unreactive pupils,
ophthalmoplegia, and
profound facial weakness. There is areflexia,
quadriplegia, and no movement
of the palate and tongue. Sensation is normal.
Babinski's sign is
absent. Which of the following is the most
appropriate pharmacotherapy?

A
) Antitoxin

B
) Azathioprine

C
) Interferon

D
) Pyridostigmine

E
) Riluzole

35. A 2325-g (5 lb 2 oz) male newborn is delivered
at 33 weeks'
gestation; Apgar scores are 7 and 8 at 1 and 5
minutes, respectively. The
13-year-old mother had no prenatal care and did not
know how much
weight she gained. During the pregnancy, the mother
smoked marijuana and
took over-the-counter vitamins occasionally; she did
not drink alcohol
and had no illness except for an upper respiratory
tract infection 4
months ago. She did not know she was pregnant until 2
weeks ago; her
family is unaware of her condition. She has had one
sexual partner. During
the hospital stay, the newborn and his mother have no
complications.
The newborn is at greatest risk for morbidity and
mortality from which
of the following?

A
) Child abuse

B
) Congenital syphilis

C
) Hypocalcemia

D
) Lead poisoning

E
) Seizures

36. A 2-month-old girl is brought to the physician
because of a
2-week history of progressive difficulty breathing and
poor feeding. She
has had rapid and labored breathing and sweating
during feedings. There
is no history of fever or viral illness. Her
temperature is 37 C (98.6
F), blood pressure is 80/60 mm Hg, pulse is 130/min,
and respirations
are 40/min. Bilateral crackles are heard at both lung
bases. A grade
4/6 holosystolic murmur is heard along the left
sternal border; the
precordium is hyperdynamic. The liver edge is
palpated 4 cm below the
right costal margin. An x-ray film of the chest shows
cardiomegaly and
pulmonary congestion. Which of the following is the
most likely
underlying mechanism for this child's condition?

A
) Decreased systemic vascular resistance

B
) Increased pulmonary vascular resistance

C
) Increased systemic vascular resistance

D
) Intracardiac left-to-right shunt

E
) Intracardiac right-to-left shunt

37. A 37-year-old man comes to the physician 6
months prior to
traveling to sub-Saharan Africa for 1 year. He has no
history of hepatitis
and has no high-risk behavior for hepatitis B. Which
of the following
is the most appropriate recommendation to prevent
hepatitis during and
after his trip?

A
) Immune globulin

B
) Hepatitis B immune globulin (HBIG) only

C
) Hepatitis B vaccine series only

D
) Hepatitis B vaccine series and HBIG

E
) Hepatitis B vaccine series and hepatitis A
vaccine

38.

A 67-year-old man comes to the physician because of a
2-month history
of progressive shortness of breath. He has had a
4.5-kg (10-lb) weight
loss over the past 4 months. He has not had chest
pain. He has
congestive heart failure treated with furosemide,
digoxin, and enalapril. He
has smoked two packs of cigarettes daily for 30 years.
He appears
alert and is in no acute distress. His temperature is
37.2 C (99 F), blood
pressure is 140/85 mm Hg, pulse is 84/min, and
respirations are 18/min.
Examination shows no jugular venous distention. There
is dullness to
percussion, and breath sounds are decreased at the
left base. Cardiac
examination shows a laterally displaced point of
maximal impulse, normal
S1 and S2, and an S3 at the apex. There is 1+ edema
over the
extremities. An x-ray film of the chest shows an
enlarged cardiac silhouette,
left hilar fullness, and a moderate-sized left pleural
effusion.
Thoracentesis yields straw-colored fluid. Laboratory
studies show:

A Gram's stain and acid-fast stains are negative for
any organisms.
Which of the following is the most likely cause of
this patient's pleural
effusion?

A
) Bacterial pneumonia

B
) Collagen vascular disease

C
) Congestive heart failure

D
) Malignancy

E
) Pulmonary embolus with infarction

F
) Viral pleuritis

39. A previously healthy 67-year-old woman is
admitted to the
hospital because of a 2-week history of dark urine,
clay-colored stools, and
increasing jaundice. She has had a 9-kg (20-lb)
weight loss over the
past 2 months due to loss of appetite. She also has
had generalized
itching that is most severe at night. She has not had
any abdominal pain.
Examination shows no abnormalities except for
jaundice. Which of the
following is the most likely diagnosis?

A
) Common bile duct stone

B
) Drug-induced jaundice

C
) Hemolytic jaundice

D
) Pancreatic carcinoma

E
) Viral hepatitis

40. A 2-year-old boy is brought to the physician
because of fever
and listlessness for 12 hours. He has had recurrent
episodes of
pneumonia and otitis media over the past year. Two
maternal uncles died of
pneumonia in early childhood. One year ago, he was at
the 50th percentile
for height and weight; he is currently at the 25th
percentile for
height and 10th percentile for weight. He appears
ill. His temperature is
39 C (102.2 F), blood pressure is 60/40 mm Hg, pulse
is 160/min, and
respirations are 36/min. Examination shows cool and
mottled extremities.
A blood culture grows Streptococcus pneumoniae. Serum
IgE, IgG, and
IgM levels are markedly decreased. Which of the
following diagnostic
tests is most likely to be abnormal?

A
) Candidal skin test

B
) Flow cytometry identification of B lymphocytes

C
) Nitroblue tetrazolium test

D
) T-lymphocyte receptor stimulation by concanavalin
A

E
) Total serum hemolytic complement assay

41. A 1-week-old newborn has had poor feeding,
vomiting, and
progressive lethargy over the past 4 days. She was
born at term; pregnancy,
labor, and delivery were uncomplicated, and she had no
congenital
anomalies. She is being breast-fed. She has a
healthy 2-year-old brother; a
sister died at 10 days of age after a full-term birth.
Examination
shows decreased muscle tone and poor responsiveness;
reflexes are normal.
Serum bicarbonate level is 8 mEq/L, pH is 7.15, and
plasma ammonia
level is 10 times the upper limit of normal. Which of
the following is the
most likely cause?

A
) Mitochondrial disorder

B
) Mucopolysaccharidoses disorder

C
) Organic acid metabolism disorder

D
) Renal tubular acidosis

E
) X-linked leukodystrophy

For each patient with an infection, select the most
likely causal
organism.

A
) Chlamydia trachomatis

B
) Clostridium botulinum

C
) Clostridium tetani

D
) Group A streptococcus

E
) Group B streptococcus

F
) Listeria monocytogenes

G
) Neisseria gonorrhoeae

H
) Streptococcus pneumoniae

42.

A premature 18-hour-old newborn is intubated and
mechanically
ventilated because of progressive respiratory
distress. Labor was complicated
by maternal fever and increased leukocyte count;
membranes ruptured 36
hours before delivery. His blood pressure and urine
output have
decreased since birth. The newborn appears acutely
ill, and peripheral pulses
are not palpable; the skin is pale, cool, and mottled.
The liver edge
is palpable 4 cm below the right costal margin. His
leukocyte count is
5000/mm3, platelet count is 48,000/mm3, and partial
thromboplastin time
is 60 sec. An x-ray film of the chest shows diffuse,
bilateral,
interstitial infiltrates.

43. A 6-year-old boy has been unable to walk for 2
days because of a
sore right knee. Three weeks ago he had a sore throat
and fever that
resolved within 2 days. He appears acutely ill. His
temperature is 39.2
C (102.5 F), and pulse is 120/min. A grade 2/6
pansystolic murmur is
heard at the apex. The right knee is red, tender, and
swollen; any
motion is painful. His leukocyte count is 15,000/mm3,
and erythrocyte
sedimentation rate is 120 mm

44. A 70-year-old woman comes to the physician
because of fatigue
and increasing difficulty in her daily functioning
over the past 2
months. During the day, she lies in bed for hours and
cries. She has had a
10.9-kg (24-lb) weight loss over the past 4 weeks,
eats only cookies,
has lost interest in almost everything, and wishes to
kill herself. Her
husband died 4 months ago. Physical examination and
laboratory studies
show normal findings except for decreased serum
albumin and total
protein levels. Which of the following is the most
likely diagnosis?

A
) Adjustment disorder with depressed mood

B
) Bereavement

C
) Bipolar disorder, depressed

D
) Dysthymic disorder

E
) Major depressive disorder

45. A 42-year-old woman comes to the physician
because of increasing
low back pain for 2 days. She is a daily intravenous
drug user. She
has a history of pyelonephritis, abscesses at
injection sites, and
pelvic inflammatory disease. Her temperature is 39 C
(102.2 F), blood
pressure is 130/70 mm Hg, pulse is 84/min, and
respirations are 20/min.
Examination shows warm, dry skin, a supple neck, and
no jugular venous
distention. There is tenderness over L4. Pelvic
examination shows mild
erythema around the cervical os and scant discharge;
there is no adnexal
or cervical motion tenderness. Her hematocrit is 30%,
leukocyte count
is 10,600/mm3, and serum glucose level is 110 mg/dL.
Urinalysis is
within normal limits. Which of the following is the
most appropriate next
step in management?

A
) Echocardiography

B
) Renal ultrasonography

C
) MRI of the back

D
) Colposcopy

E
) Laparoscopy

46. A 13-year-old boy is brought to the physician
by his mother
because of frequent headaches over the past 5 weeks.
He describes the
headaches as dull pain across his forehead; they occur
four to five times
weekly. Acetaminophen does not relieve the pain. His
mother states
that occasionally he has nausea without vomiting. He
has schizophrenia
well controlled with risperidone. Physical
examination shows no
abnormalities. An MRI of the brain is most likely to
show which of the
following?

A
) Bilateral increased caudate nuclei

B
) Decreased cerebellar volume

C
) Hippocampal symmetry

D
) Increased lateral ventricle size

E
) Multiple white-matter hyperintensities
Report Abuse

* block 3:---

dolly123 - 11/07/06 17:59 #548031

1. A 42-year-old woman, gravida 2, para 2, comes to
the physician
because of a 3-month history of swelling of her legs
and mild abdominal
pain and bloating. Abdominal examination shows no
abnormalities.
Rectovaginal examination shows fullness in the right
adnexa. Transvaginal
ultrasonography shows an irregular mass in the right
ovary with some
solid components to a predominantly cystic lesion.
Her serum CA 125 level
is 120 U/mL (N<35). Treatment with which of the
following is most
likely to have prevented this patient's symptoms?

A
) Antiestrogens

B
) Antiprogestationals

C
) Medroxyprogesterone

D
) Oral contraceptives

E
) Ovulation-inducing drugs

2. A 15-year-old girl is brought to the physician 3
months after she
had a blood pressure of 150/95 mm Hg at a routine
examination prior to
participation in school sports. She is asymptomatic
and has no history
of serious illness. Twelve months ago, she was
diagnosed with a
urinary tract infection and treated with oral
trimethoprim-sulfamethoxazole.
She currently takes no medications. Subsequent blood
pressure
measurements on three separate occasions since the
last visit have been: 155/94
mm Hg, 145/90 mm Hg, and 150/92 mm Hg. She is at the
50th percentile
for height and 95th percentile for weight. Her blood
pressure today is
150/90 mm Hg confirmed by a second measurement, pulse
is 80/min, and
respirations are 12/min. Examination shows no other
abnormalities. Her
hematocrit is 40%. Urinalysis is within normal limits.
Cardiac and
renal ultrasonography shows no abnormalities. Which
of the following is
the most appropriate next step in management?

A
) Exercise and weight reduction program

B
) Measurement of urine catecholamine levels

C
) Measurement of urine corticosteroid levels

D
) Captopril therapy

E
) Hydrochlorothiazide therapy

3. Over the past 4 years, a 40-year-old woman has
had increasing
episodes of loss of urine and difficulty emptying her
bladder. She has
had no dysuria. She has a 30-year history of type 1
diabetes mellitus.
She weighs 66 kg (145 lb) and is 175 cm (69 in) tall.
Pelvic
examination shows a moderate cystocele. Postvoiding
catheterization yields 700
mL of clear urine. Which of the following is the most
likely cause of
the patient's genitourinary symptoms?

A
) Carcinoma of the bladder

B
) Detrusor instability

C
) Neurogenic bladder

D
) Urethral diverticulum

E
) Uterine prolapse

4. A 57-year-old man comes to the emergency
department because of an
episode of confusion, nervousness, sweating, and
palpitations 1 hour
ago. He has had four similar episodes over the past 3
weeks; they last 2
to 3 minutes and are relieved by ingesting solid food
or liquids. His
blood pressure is 140/74 mm Hg, pulse is 76/min, and
respirations are
18/min. Examination shows no other abnormalities.
The most appropriate
next step in diagnosis is serum measurement of which
of the following?

A
) Fasting gastrin level

B
) Fasting insulin and glucose levels

C
) Glucagon level

D
) Glucose and somatostatin level

E
) Glucose and vasoactive intestinal

5. An otherwise healthy 15-year-old girl is brought
to the physician
because she has never had a menstrual period. She
reports that breast
development started 1 year ago and pubic and axillary
hair development
began 6 months ago. Examination shows normal
genitalia. Breast
development is Tanner stage 4, and pubic hair
development is Tanner stage 3.
Which of the following is the most appropriate next
step in management?

A 2-month-old boy is brought to the physician because
of a 6-week
history of persistent diarrhea and vomiting, most
pronounced after formula
feedings. He has had a 113-g (4-oz) weight loss since
birth. He
currently weighs 3100 g (6 lb 13 oz) and is 51 cm (20
in) in length. He
appears irritable. Examination shows jaundice. The
lungs are clear to
auscultation. No murmurs are heard. The liver is
palpated 2 to 3 cm
below the right costal margin, and the spleen is
palpated 1 to 2 cm below
the left costal margin. Laboratory studies show:

Which of the following is the most likely mechanism of
these findings?

A
) Decreased gluconeogenesis

B
) Decreased insulin secretion

C
) Increased glucagon secretion

D
) Increased gluconeogenesis

E
) Increased insulin secretion

F
) Insulin resistance

7. A 75-year-old man has had hypertension for 25
years. There is an
unusually prominent pulsation of the abdominal aorta
in the upper
midabdomen. A systolic bruit is heard at this site.
Femoral, popliteal, and
pedal pulses are present. Which of the following is
the most
appropriate initial diagnostic study?

A
) X-ray film of the abdomen

B
) Abdominal ultrasonography

C
) Doppler ultrasonography of the arteries of the
legs

D
) Abdominal aortography

E
) Intravenous pyelography

8. A 14-year-old boy is brought to the physician
because of constant
right knee pain for 2 weeks. The pain is not relieved
by rest or
analgesics. There is no history of trauma. He is at
the 50th percentile
for height and above the 95th percentile for weight.
He walks with a
limp but is not in distress. His vital signs are
within normal limits.
Examination shows full range of motion of both knees;
passive abduction
and internal rotation of the right hip produce pain.
There is no
swelling of either knee or hip. Neurologic
examination shows no
abnormalities. Which of the following is the most
likely diagnosis?

A
) Juvenile rheumatoid arthritis

B
) Osgood-Schlatter disease

C
) Septic arthritis

D
) Slipped capital femoral epiphysis

E
) Toxic synovitis

9. A previously healthy 72-year-old man comes to
the physician
because of a 2-year history of hand tremors and
progressive difficulty
walking. He lives alone and has no close relatives.
He is alert and
oriented. Physical examination shows a decreased rate
of eye blinking.
Neurologic examination shows masked facies and a
pill-rolling resting
tremor of both hands. There is cogwheel rigidity of
the upper extremities
and generalized bradykinesia. His handwriting has
become small and
illegible. He has a slow, shuffling, festinating gait
with a tendency to
lean forward. Postural reflexes are impaired. This
patient is at
greatest risk for injury due to which of the
following?

A
) Bradykinesia

B
) Cogwheel rigidity

C
) Decreased rate of eye blinking

D
) Postural reflex impairment

E
) Tremor

10. A 47-year-old woman comes for a routine health
maintenance
examination. She has a 10-year history of type 2
diabetes mellitus that is
well controlled with an oral hypoglycemic agent. Her
mother died of a
myocardial infarction at the age of 38 years. The
patient weighs 82 kg
(180 lb) and is 163 cm (64 in) tall. Her blood
pressure is 150/95 mm
Hg. Examination shows multiple small skin tags below
the eyebrows and
on the nose and eyelids. Which of the following is
the most appropriate
next step in diagnosis?

A
) Measurement of serum follicle-stimulating hormone
level

B
) Serum lipid studies

C
) 24-Hour urine collection for measurement of
creatinine clearance

D
) X-ray film of the chest

E
) ECG

F
) No further studies indicated

11.

A previously healthy 15-year-old boy is brought to the
physician
because of a 5-day history of fever, intractable
nausea and vomiting, sore
throat, and muscle pain. His mother has been giving
him ibuprofen and
amoxicillin that was remaining from a previous
streptococcal throat
infection. He appears ill, and his lips are parched.
His temperature is
38.9 C (102 F), blood pressure is 120/74 mm Hg while
supine and 100/70 mm
Hg while standing, and pulse is 92/min while supine
and 120/min while
standing. Examination shows dry mucous membranes.
The oropharynx is
erythematous without exudate. There is shotty
cervical adenopathy. The
abdomen is soft without organomegaly. Laboratory
studies show:

Which of the following is the most likely explanation
for this
patient's renal insufficiency?

A
) Acute tubular necrosis

B
) Amoxicillin-induced acute interstitial nephritis

C
) Ibuprofen-induced renal failure

D
) Post-streptococcal glomerulonephritis

E
) Severe volume depletion

12. A 77-year-old woman is brought to the emergency
department after
collapsing at home. Six hours ago, she had the sudden
onset of massive
bright red rectal bleeding. On arrival, her blood
pressure is 90/60 mm
Hg, and pulse is 120/min. Abdominal examination shows
no
abnormalities. Insertion of a nasogastric tube yields
clear aspirate. Her
hematocrit is 28%. Which of the following is the most
likely diagnosis?

A
) Colon cancer

B
) Diverticulosis

C
) Duodenal ulcer

D
) Hemorrhoids

E
) Inflammatory bowel disease

13. A previously healthy 27-year-old woman comes to
the emergency
department 1 hour after a 30-minute episode of
shortness of breath,
nausea, diaphoresis, and crushing substernal chest
pain radiating to the
left shoulder; the episode resolved spontaneously.
She is currently
asymptomatic. Her blood pressure is 110/84 mm Hg,
pulse is 70/min, and
respirations are 16/min. Examination shows no
abnormalities. An ECG shows
a normal sinus rhythm and no other abnormalities. Ten
minutes later,
she sits up in bed stating that her symptoms have
returned. Her blood
pressure now is 150/105 mm Hg, pulse is 120/min, and
respirations are
24/min. A repeat ECG shows 5-mm ST-segment elevation
in leads II, III,
and aVF. Her symptoms resolve after administration of
aspirin and
nitroglycerin. An angiography is ordered and shows no
evidence of coronary
atherosclerosis. Which of the following is the most
appropriate
pharmacotherapy?

A
) Angiotensin-converting enzyme (ACE) inhibitor

B
) Aspirin

C
) Benzodiazepine

D
) Calcium-channel blocking agent

E
) Corticosteroids

F
) Thiazide diuretic

Na+(mEq/L) Cl–(mEq/L) K+(mEq/L) HCO3–(mEq/L)
pH Specific
gravity

A
)
132 89 2.8 39 5.0 1.025

B
)
133 110 3.9 16 6.0 1.015

C
)
163 117 4.3 22 5.5 1.003

D
)
165 115 4.5 19 5.0 1.030

14. An 8-week-old boy is brought to the physician
by his mother
because of persistent vomiting for 2 days. He has
spit up intermittently
since birth. He has had no diarrhea. He appears
irritable. His
temperature is 38 C (100.4 F), blood pressure is 90/60
mm Hg, pulse is
130/min, and respirations are 25/min. Examination
shows a sunken anterior
fontanelle. Mucous membranes are dry. The lungs are
clear to
auscultation. Heart sounds are normal. The abdomen
is scaphoid, and bowel
sounds are active.

15. A 7-week-old boy is brought to the physician
because of fever,
irritability, and lethargy for 3 days. He has had no
vomiting,
diarrhea, or symptoms of an upper respiratory tract
infection. He always seems
hungry to his mother despite being fed 3 ounces of
formula every 3
hours. His mother also notes that he has many wet
diapers throughout the
day and night. He currently appears irritable. His
temperature is 37.8
C (100 F), blood pressure is 80/50 mm Hg, pulse is
150/min, and
respirations are 25/min. Examination shows a sunken
anterior fontanelle.
Mucous membranes are dry. There is tenting of the
skin. Examination
shows no other abnormalities. Urinalysis is negative
for glucose and
protein.

16.

A 57-year-old woman is extubated and transferred to
the recovery room
after a cholecystectomy. She appears restless. Her
blood pressure is
120/70 mm Hg, pulse is 80/min, and respirations are
10/min. Arterial
blood gas analysis on room air shows:

pH 7.24
PCO2 85 mm Hg
PO2 60 mm Hg

Intravenous naloxone therapy is begun, but she does
not improve. Which
of the following is the most appropriate next step in
management?

A
) Encouraging deep breathing and cough

B
) Administration of 40% oxygen via nasal cannula

C
) Administration of furosemide

D
) Transfusion of 1 unit of packed red blood cells

E
) Reintubation and mechanical ventilation

17. A previously healthy 24-year-old woman is
brought to the
physician by her husband because of several episodes
of loss of consciousness
over the past 4 days. Her husband reports that during
episodes, she
jerks her arms and legs wildly. Each episode lasts up
to 1 hour; between
episodes, her behavior is normal. She is planning to
move to another
state because of her husband's work. She has been
extremely anxious and
upset about the move because she will have to leave
her mother, who was
recently diagnosed with breast cancer. There is no
family history of
seizure disorder. Her temperature is 36.7 C (98 F),
blood pressure is
130/80 mm Hg, pulse is 84/min, and respirations are
18/min. Neurologic
examination shows no abnormalities.
Electroencephalography shows
normal findings during an episode of shaking. Which
of the following is the
most likely underlying cause?

A
) Catatonia

B
) Complex partial seizure

C
) Conversion reaction

D
) Dissociative fugue

E
) Malingering

F
) Tonic-clonic seizure

18. A 37-year-old man comes to the physician
because of a 3-month
history of increasing pain of his shoulders and upper
arms. Over the
past 2 weeks, he has also had difficulty lifting heavy
objects off shelves
in his garage. Two days ago, he burned his hand by
touching a hot pan
and felt little discomfort. He sustained a concussion
in a motor
vehicle collision at the age of 29 years. He has no
allergies. He takes no
medications. He does not smoke cigarettes or use
illicit drugs, and he
drinks one to two beers daily. Muscle strength is
decreased equally in
both arms. Temperature and pain sensation are
decreased in both hands,
but light touch is normal. Muscle strength and
sensation are normal in
the lower extremities. Neurologic examination shows
no other
abnormalities. Which of the following is the most
likely diagnosis?

A
) Alcoholic peripheral neuropathy

B
) Ankylosing spondylitis

C
) Guillain-Barré syndrome

D
) Herniated intervertebral disc

E
) Multiple sclerosis

F
) Polymyositis

G
) Syringomyelia

19. A 62-year-old woman with ovarian cancer comes
to the emergency
department because of fever for 2 days. Ten days ago,
she received
chemotherapy with paclitaxel and carboplatin. She
feels tired but has not
had nausea or vomiting. Her temperature is 39.5 C
(103.1 F), blood
pressure is 100/60 mm Hg, and pulse is 115/min. The
lungs are clear to
auscultation. Examination shows a soft, nontender
abdomen. Her
hematocrit is 32%, leukocyte count is 800/mm3, and
platelet count is
105,000/mm3. Serum electrolyte levels are within
normal limits. Which of the
following is the most appropriate next step in
treatment?

A
) Plasmapheresis

B
) Additional chemotherapy

C
) Intravenous antibiotic therapy

D
) Intravenous corticosteroid therapy

E
) Transfusion of 2 units of leukocytes

F
) Transfusion of 2 units of packed red blood cells

20.

A 47-year-old woman who is visiting from Australia
comes to the
physician because of increasing urine output over the
past month. She has had
no dysuria or hematuria. She has a history of chronic
headaches,
peptic ulcer disease, and urinary tract infections.
An evaluation 18 months
ago for headaches, including CT scan of the head,
showed no
abnormalities; treatment with ibuprofen and phenacetin
was initiated at that time,
and her headaches have been well controlled. Her
temperature is 37.1 C
(98.8 F), blood pressure is 140/82 mm Hg, pulse is
78/min, and
respirations are 14/min. Examination shows no
abnormalities. Laboratory
studies show:

Test of the stool for occult blood is negative. Which
of the following
is the most appropriate next step in management?

A
) Intravenous pyelography

B
) Discontinue current medication

C
) Antibiotic therapy for recurrent urinary tract
infections

D
) Insulin therapy for diabetes mellitus

E
) Upper endoscopy

20.

A 47-year-old woman who is visiting from Australia
comes to the
physician because of increasing urine output over the
past month. She has had
no dysuria or hematuria. She has a history of chronic
headaches,
peptic ulcer disease, and urinary tract infections.
An evaluation 18 months
ago for headaches, including CT scan of the head,
showed no
abnormalities; treatment with ibuprofen and phenacetin
was initiated at that time,
and her headaches have been well controlled. Her
temperature is 37.1 C
(98.8 F), blood pressure is 140/82 mm Hg, pulse is
78/min, and
respirations are 14/min. Examination shows no
abnormalities. Laboratory
studies show:

Test of the stool for occult blood is negative. Which
of the following
is the most appropriate next step in management?

A
) Intravenous pyelography

B
) Discontinue current medication

C
) Antibiotic therapy for recurrent urinary tract
infections

D
) Insulin therapy for diabetes mellitus

E
) Upper endoscopy

21. A previously healthy 85-year-old man has had
abdominal
distention, decreased caliber of stools, and decreased
appetite over the past 2
weeks and a 9-kg (20-lb) weight loss over the past 3
months. On
sigmoidoscopy, he is found to have a constricting
adenocarcinoma of the
sigmoid colon; imaging studies show three 1-cm
metastases to the liver.
Which of the following is the most appropriate next
step in management?

A
) No treatment

B
) Radiation therapy

C
) Chemotherapy

D
) Combination radiation therapy and

chemotherapy

E
) Resection of the colon tumor

22. An 8-year-old girl with asthma is brought to
the physician 1
week after an acute exacerbation treated with a 5-day
taper course of oral
prednisone. This was her first asthma attack of the
fall season.
Medications include an inhaled corticosteroid daily
and a bronchodilator
metered-dose inhaler as needed. Her last
immunizations were at the age
of 5 years prior to entering kindergarten. Her
temperature is 37 C
(98.6 F), pulse is 92/min, and respirations are
28/min. Examination shows
end-expiratory wheezing with forced expiration.
Administration of
which of the following vaccines is most appropriate at
this visit?

A
) Haemophilus influenzae type b

B
) Influenza virus

C
) Meningococcal

D
) 23-Valent pneumococcal

E
) Varicella

23. A 27-year-old man is brought to the hospital by
family members
because he has remained in his room for 3 days. He
has refused to go to
work or eat with the family, and he expresses concern
that family or
friends may try to kill him. One week ago, he was
despondent when his
girlfriend of 5 years abruptly ended their
relationship. He has no
history of psychiatric illness. Which of the following
is the most likely
diagnosis?

A
) Adjustment disorder with depressed mood

B
) Bipolar disorder

C
) Brief psychotic disorder

D
) Dysthymic disorder

E
) Schizoaffective disorder

24. A 35-year-old primigravid woman at 20 weeks'
gestation comes to
the physician because of vaginal pressure and a
watery, pink vaginal
discharge for 1 day. Her temperature is 37.5 C (99.5
F). The uterus is
palpated at the umbilicus. Fetal heart rate is
140/min. Speculum
examination shows that the upper vagina is filled with
bulging, shiny,
smooth membranes. The cervix cannot be palpated.
Which of the following is
the most likely mechanism for these findings?

A
) Abruptio placentae

B
) Cervical incompetence

C
) Premature labor

D
) Uterine anomaly

E
) Uterine infection

25. A previously healthy 45-year-old woman has had
fever and
progressive confusion over the past 2 days. She is
now unable to perform
activities of daily living. Her temperature is 38 C
(100.4 F). She is
oriented only to person. There is no rash, and the
neck is supple. A CT
scan of the head shows normal findings. Cerebrospinal
fluid analysis
shows:

26. A 57-year-old man with multiple myeloma comes
to the physician
because of a 12-hour history of fever, sharp chest
pain with deep
inspiration, and cough productive of blood-tinged
sputum. His temperature is
38.3 C (101 F), blood pressure is 120/78 mm Hg, pulse
is 112/min, and
respirations are 28/min. Crackles are heard at the
right lung base.
His hemoglobin level is 9.2 g/dL, leukocyte count is
2600/mm3, and
platelet count is 96,000/mm3. Empiric antibiotics
should be directed against
which of the following organisms?

A
) Listeria monocytogenes

B
) Neisseria meningitidis

C
) Pseudomonas aeruginosa

D
) Streptococcus bovis

E
) Streptococcus pneumoniae

27. A 19-year-old primigravid woman is brought to
the emergency
department because of a 4-hour history of heavy
vaginal bleeding. She has
vomited daily for the past month. Her last menstrual
period was 15
weeks ago. She has not received prenatal care. She
takes no medications.
Her temperature is 37 C (98.6 F), blood pressure is
140/90 mm Hg, pulse
is 80/min, and respirations are 20/min. Abdominal
examination shows a
uterus consistent in size with a 20-week gestation
with no adnexal
masses or tenderness. There is pedal edema. A serum
pregnancy test is
positive. Urinalysis shows 1+ protein. Which of the
following is the
most likely cause of this patient's vaginal bleeding?

A
) Abruptio placentae

B
) Ectopic pregnancy

C
) Hydatidiform mole

D
) Hyperthyroidism

E
) Preeclampsia

28. A 40-year-old man has the sudden onset of
excruciating head and
neck pain while carrying books from the basement to
the attic. His
temperature is 37 C (98.6 F), blood pressure is 130/90
mm Hg, and pulse is
90/min. He has photophobia and develops eye pain with
lateral eye
movements. His neck is markedly stiff and cannot be
passively flexed. He
has diffuse hyperreflexia in all extremities with
normal strength and
sensation. Plantar reflexes are flexor bilaterally.
Which of the
following is the most likely diagnosis?

A
) Cervical osteoarthritis

B
) Meningitis

C
) Ruptured cervical disc

D
) Subarachnoid hemorrhage

E
) Syringomyelia

29. A 59-year-old woman comes to the emergency
department because of
shortness of breath for 2 days. She had stage II
breast cancer 5 years
ago treated with lumpectomy, radiation, and
chemotherapy. Her
temperature is 37.5 C (99.5 F), blood pressure is
90/60 mm Hg, and respirations
are 24/min. Examination shows jugular venous
distention. Heart sounds
are distant. Which of the following is the most
appropriate next step
in management?

A
) Antibiotic therapy

B
) Anticoagulant therapy

C
) Intravenous digoxin therapy

D
) Intravenous furosemide therapy

E
) Chemotherapy

F
) Radiation therapy

G
) Pericardiocentesis

30. A 57-year-old man comes for a routine follow-up
examination. He
has a 10-year history of an intermittent facial rash.
He has been
taking propranolol for 2 months for hypertension.
Examination shows
several erythematous pustules and papules involving
the nose and central
face. There are telangiectasias at the base of the
papules. Which of the
following is the most likely explanation for these
findings?

A
) Acne rosacea

B
) Acne vulgaris

C
) Basal cell carcinoma

D
) Discoid lupus erythematosus

E
) Seborrheic dermatitis

31. A 42-year-old man comes to the physician
because of malaise,
muscle and joint pain, and temperatures to 38.4 C
(101.1 F) for 3 days.
Three months ago, he underwent cadaveric renal
transplantation resulting
in immediate kidney function. At the time of
discharge, his serum
creatinine level was 0.8 mg/dL. He is receiving
cyclosporine and
corticosteroids. Examination shows no abnormalities.
His leukocyte count is
2700/mm3, and serum creatinine level is 1.6 mg/dL;
serum cyclosporine
level is in the therapeutic range. A biopsy of the
transplanted kidney
shows intracellular inclusion bodies. Which of the
following is the most
appropriate next step in management?

A
) Increase the dosage of corticosteroids

B
) Increase the dosage of cyclosporine

C
) Begin amphotericin therapy

D
) Begin ganciclovir therapy

E
) Begin heparin therapy

32. A 5-month-old boy is brought to the physician
because of a
24-hour history of fever, cough, noisy breathing, and
difficulty feeding.
His symptoms began 3 days ago with nasal discharge,
mild cough, and
chest congestion. He appears somewhat irritable and
is crying. His
temperature is 38.5 C (101.3 F), pulse is 108/min, and
respirations are
32/min and shallow with a prolonged expiratory phase.
On examination, the
throat appears normal. A few small anterior and
posterior cervical
nodes are palpable. Both eardrums are pink but have
normal landmarks and
mobility. There is good air entry with diffuse
bilateral expiratory
wheezes on auscultation. An x-ray film of the chest
shows hyperinflation.
Which of the following is the most likely pathogen?

A
) Adenovirus

B
) Haemophilus influenzae

C
) Mycoplasma pneumoniae

D
) Respiratory syncytial virus

E
) Streptococcus pneumoniae

3. Three days after undergoing a right hip
replacement for
rheumatoid arthritis, a 77-year-old man is brought to
the physician because of a
2-day history of pain, burning, and itching of his
left eye and left
side of his forehead. He has the sensation that there
is a speck of dirt
in his left eye. Current medications include
prednisone and
methotrexate. Examination of the left eye shows
conjunctival injection and
swelling of the upper eyelid. There is an
erythematous rash over the left
side of the forehead and tenderness to palpation from
the upper eyelid
to the vertex. A photograph of the rash is shown.
Which of the
following is the most appropriate next step in
management?

A
) Measurement of erythrocyte sedimentation rate

B
) MRI of the brain with contrast

C
) Acyclovir therapy

D
) Corticosteroid therapy

E
) Lumbar puncture

34. A 54-year-old man with chronic obstructive
pulmonary disease
undergoes a total hip arthroplasty for avascular
necrosis of the femoral
head. On the second postoperative day, he has
diffuse, profound
weakness and vomiting. His blood pressure is 85/50 mm
Hg, and pulse is
100/min. The operative site is clean and dry, with
minimal output from the
drains. Hemoglobin level is 13.8 g/dL, serum sodium
level is 132 mEq/L,
and serum potassium level is 5.8 mEq/L. Which of the
following is most
likely to confirm the diagnosis?

A
) Measurement of serum thyroid-stimulating hormone
level

B
) Direct antiglobulin (Coombs') test

C
) ACTH stimulation test

D
) Ventilation-perfusion lung scans

E
) Echocardiography

35. A previously healthy 47-year-old nulliparous
woman is brought to
the emergency department by ambulance because of acute
low back pain
radiating to the right posterior leg for 2 hours. The
pain began when
she bent over at work to retrieve a file from the
lowest drawer of a
filing cabinet. She does not smoke cigarettes or
drink alcohol.
Examination shows right paraspinous muscle spasm and
pain in the lower back with
right straight-leg raising at 30 degrees. She says
that she plans to
file a claim for a work-related injury. Which of the
following findings
is the strongest risk factor for a prolonged episode
of pain in this
patient?

A
) Arrival for care in an ambulance

B
) Claim that pain is work-related

C
) Gender

D
) Nulliparity

E
) Positive straight-leg raising test

F
) Radiation of the pain into the posterior lower
extremity

36. A healthy 27-year-old woman comes to the
physician for an annual
examination. She is concerned about her risk for an
abnormal Pap smear
in the future. A history of use of which of the
following would
increase her risk for cervical cancer?

A
) Alcohol

B
) Cervical cap

C
) Cigarettes

D
) Isotretinoin

E
) IUD

37. A 72-year-old man is brought to the physician
by his daughter
because of painless jaundice for 1 month. His wife
died 10 years ago,
and his daughter is his only child. Before examining
the patient, the
daughter asks to speak privately with the physician
and asks that she be
given the results of any tests. She specifically
requests that he not
be given any "bad news." The patient is alert. His
vital signs are
within normal limits. Examination shows scleral
icterus and jaundice.
There is mild abdominal tenderness on palpation. He
is oriented to
person, place, and time. A CT scan of the abdomen
shows a pancreatic mass
with bile duct obstruction and probable metastatic
lesions in the
liver. Which of the following is the most appropriate
next step?

A
) Abide by the daughter's wishes

B
) Ask the patient if he wishes to discuss his test
results,
preferably with his daughter present

C
) Tell the daughter it is a legal requirement to
tell the patient
any and all results of medical testing

D
) Consult with the hospital attorney

E
) Ask another physician to take over the

patient's care

38. A 66-year-old man has had numbness and tingling
in the hands and
feet for 2 weeks. He lives in a homeless shelter and
is well fed. He
has been treated for pulmonary tuberculosis for 4
months with
isoniazid, rifampin, ethambutol, and pyrazinamide. He
is compliant with his
medication regimen but continues to abuse alcohol.
His temperature is 37
C (98.6 F), blood pressure is 136/76 mm Hg, pulse is
72/min, and
respirations are 20/min. He is well nourished but
depressed and irritable.
There is decreased sensation to pain and touch in the
hands and feet in
a stocking-glove distribution. Which of the following
is the most
likely nutritional deficiency?

A
) Folic acid

B
) Niacin

C
) Vitamin A

D
) Vitamin B1 (thiamine)

E
) Vitamin B2 (riboflavin)

F
) Vitamin B6

G
) Vitamin B12 (cyanocobalamin)

H
) Vitamin C

I
) Vitamin D

J
) Vitamin E

K
) Vitamin K

39. A 63-year-old man is brought to the emergency
department 3 hours
after the acute onset of severe right-sided flank
pain. He has a
9-year history of gout. His blood pressure is 110/84
mm Hg, pulse is
78/min, and respirations are 16/min. Examination
shows normal bowel sounds
and no abdominal tenderness or masses. Urinalysis
shows 40
erythrocytes/hpf. Intravenous pyelography confirms a
right ureteral calculus.
Which of the following is the most likely underlying
mechanism of this
patient's urolithiasis?

A
) An increase in urinary pH

B
) Damage to the epithelial lining of the ureters

C
) Lack of inhibitors of crystal formation

D
) Presence of urease-splitting bacteria

E
) Urinary supersaturation with uric acid

40. A 27-year-old nulligravid woman comes to the
physician for
preconceptional counseling. She has a mechanical
mitral heart valve and
chronic rheumatoid arthritis. Her cardiac status is
New York Heart
Association Class II. She feels well. Current daily
medications include
warfarin, prednisone, and acetaminophen with codeine.
Examination shows
no abnormalities except for audible clicking from the
heart valve.
Which of the following is the most appropriate advice
for this patient?

A
) Chemical dependency counseling before pregnancy

B
) Discontinuation of anticoagulant therapy during
pregnancy

C
) Discontinuation of prednisone during pregnancy

D
) Switching from warfarin to heparin before
pregnancy

E
) No change in treatment before or during pregnancy

41. A 60-year-old man comes to the physician
because of difficulty
sleeping and concentrating and a 5-kg (10-lb) weight
loss over the past
3 months. He also has become withdrawn. He has had
chronic pain since
sustaining fractures of the left lower extremity,
pelvis, and several
ribs in a motor vehicle collision 2 years ago. He has
a previous
history of alcohol abuse. He takes a nonsteroidal
anti-inflammatory drug.
Which of the following is the most appropriate
pharmacotherapy?

A
) Carbamazepine

B
) Chlordiazepoxide

C
) Disulfiram

D
) Lithium carbonate

E
) Nortriptyline

42. An 82-year-old man comes to the physician
because of a 3-day
history of low back pain that radiates to the right
leg. He also has had
a lesion over the right shin and weakness of the right
foot. He began
taking prednisone 2 weeks ago for acute bronchitis.
He has chronic
obstructive pulmonary disease, benign prostatic
hypertrophy, and glaucoma.
Examination shows numerous papular and vesicular
lesions over the right
anterior and posterior shin. There is weakness of
right knee flexion,
ankle dorsiflexion, plantar flexion, eversion, and
inversion; the right
ankle reflex is absent. Sensation to pinprick and
cold is decreased
over the right lower extremity. Which of the
following is the most
likely causal organism?

A
) Borrelia burgdorferi

B
) Epstein-Barr virus

C
) Herpes simplex virus 1

D
) Poliovirus

E
) Treponema pallidum

F
) Varicella-zoster virus

43. A 30-year-old woman comes to the physician
because of
long-standing unhappiness that may have started when
she was rejected by her
classmates as a teenager. She says that although she
has good days, many
days are dominated by negative thoughts about herself.
She appears
somewhat sad and tends to be readily critical of
herself. Although she
sleeps satisfactorily, she often finds her energy
level decreased by the
end of the day. She also has been forgetful. She
weighs 59 kg (130 lb)
and is 157 cm (62 in) tall. Physical examination and
laboratory
studies show no abnormalities. Which of the following
is the most likely
diagnosis?

A
) Adjustment disorder with depressed mood

B
) Depersonalization disorder

C
) Dissociative identity disorder

D
) Dysthymic disorder

E
) Hypothyroidism

F
) Major depressive disorder

G
) Schizoaffective disorder

For each patient with cough, select the most
appropriate next step in
diagnosis.

A
) Measurement of serum a1-antitrypsin level

B
) Methacholine challenge test

C
) Quantitative measurement of serum antibody levels

D
) Sweat chloride test

E
) Ventilation-perfusion lung scans

44. A 27-year-old woman comes to the physician
because of
intermittent episodes of shortness of breath and cough
over the past 4 months.
She says that cold weather and exercise can
precipitate her symptoms.
Examination shows no abnormalities. The lungs are
clear to auscultation
and percussion. An x-ray film of the chest and
spirometry show no
abnormalities.

A 32-year-old woman comes to the physician because of
a 4-month history
of fatigue, cough, and shortness of breath with
exertion. She has had
two episodes of pneumonia and one episode of severe
sinusitis over the
past 2 years. She has never smoked. She takes no
medications.
Crackles are heard at the left lung base. An x-ray
film of the chest shows a
left lower lobe infiltrate and scarring of the right
base.

46. A 32-year-old man is brought to the emergency
department 30
minutes after being involved in a motor vehicle
collision. He was the
restrained driver. On arrival, he is alert and has
shortness of breath.
His blood pressure is 80/50 mm Hg, pulse is 130/min,
and respirations
are 30/min. Examination shows jugular venous
distention and abrasions
over the left hemithorax. The trachea is deviated to
the right. Breath
sounds are absent on the left. Which of the following
is the most
likely cause of the hypotension?

A
) Cardiogenic shock

B
) Congestive heart failure

C
) Decreased systemic vascular resistance

D
) Decreased venous return

E
) Hypovolemic hypoperfusion

F
) Increased systemic vascular resistance

BLOCK 4:--

1. A previously healthy 2-year-old boy is brought
to the physician
20 minutes after an episode of cyanosis and loss of
consciousness that
lasted 3 minutes. The symptoms occurred after his
mother scolded him
for climbing onto the dining room table. The mother
says that the child
began to cry, let out a deep sigh, stopped breathing,
and jerked his
arms and legs back and forth. On arrival, he is alert
and active.
Neurologic examination shows no focal findings. Which
of the following is
the most appropriate next step in management?

A
) Reassurance

B
) Electroencephalography

C
) CT scan of the head

D
) Anticonvulsant therapy

E
) Lumbar puncture

2. A case-control study is conducted to assess the
risk for
intussusception in infants under the age of 1 year who
receive the rotavirus
vaccine. The medical records of all those who
received the vaccine and
those who did not receive the vaccine over a 6-month
period are
reviewed. Results show 125 cases per 100,000
infant-years for infants who
received the vaccine compared to 45 cases per 100,000
infant-years for
infants who did not receive the vaccine. The
investigators conclude that
the relative risk for intussusception is 1.9 times
greater in infants
who receive the rotavirus vaccine (95% confidence
interval of 0.5–7.7 and
p=0.39). Which of the following is the most accurate
interpretation of
these results?

A
) The results do not show an association between
rotavirus vaccine
and intussusception, but they may be related

B
) The results show sufficient statistical power to
identify an
association between rotavirus vaccine and
intussusception

C
) Rotavirus vaccine is associated with a 39% risk
for
intussusception

A 42-year-old woman, gravida 3, para 3, comes to the
emergency
department 24 hours after the onset of moderate
epigastric pain radiating to
the back. Her last menstrual period was 3 weeks ago.
She has no history
of serious illness and has never undergone an
operative procedure. She
weighs 72 kg (160 lb) and is 157 cm (62 in) tall. Her
temperature is
37.2 C (99 F), blood pressure is 130/90 mm Hg, and
pulse is 100/min.
Abdominal examination shows mild distention,
epigastric tenderness, and
voluntary guarding. Test of the stool for occult
blood is negative.
Laboratory studies show:

Ultrasonography shows gallstones; the gallbladder wall
is 1 mm and the
common bile duct is 5 mm in diameter. Which of the
following is the
most likely diagnosis?

A
) Acute cholecystitis

B
) Acute pancreatitis

C
) Acute perihepatitis

D
) Ascending cholangitis

E
) Duodenal ulcer

F
) Viral hepatitis

4. A 13-year-old girl is brought to the emergency
department because
of shortness of breath for 2 hours. The symptoms
began after consuming
chili, cornbread, and fruit salad with strawberries,
kiwi, and bananas.
She has a 1-year history of shortness of breath while
playing soccer or
baseball and uses a bronchodilator inhaler as needed
while exercising.
She is allergic to penicillin and pineapples. Her
blood pressure is
80/60 mm Hg, pulse is 120/min and regular, and
respirations are 20/min
with use of accessory muscles. Examination of the
lungs shows poor air
entry bilaterally with diffuse expiratory wheezes.
Which of the
following is the most appropriate initial
pharmacotherapy?

A
) Inhaled bronchodilators

B
) Inhaled cromolyn sodium

C
) Inhaled ipratropium bromide

D
) Intravenous corticosteroids

E
) Subcutaneous epinephrine

5.

A 52-year-old woman comes to the emergency department
6 days after knee
arthroplasty because of constant, right-sided chest
pain and shortness
of breath for 24 hours. Her blood pressure is 110/50
mm Hg, pulse is
114/min, and respirations are 24/min. Examination of
the heart, lungs,
and extremities shows no abnormalities. Arterial
blood gas analysis on
room air shows:

pH 7.49
PCO2 29 mm Hg
PO2 66 mm Hg

Ventilation-perfusion lung scans show a low
probability for pulmonary
embolus. An ECG shows sinus tachycardia; an x-ray
film of the chest
shows no abnormalities. After the evaluation, the
patient is pain-free
and wishes to go home. Which of the following is the
most appropriate
next step in management?

A
) Discharge home and reexamination in 2 weeks

B
) Exercise stress test

C
) Pulmonary function tests

D
) Echocardiography

E
) Pulmonary angiography

F
) Ibuprofen therapy

6. A 25-year-old woman comes to the physician
because of "spells"
characterized by sweating, palpitations, and shortness
of breath that
have awakened her at night several times over the past
3 months. She
resigned from her job as a sales clerk 6 months ago
and now works from home
as a telemarketer. She recently began going to the
grocery store late
at night because she is too nervous around people.
She says that she
has been feeling sad lately. On mental status
examination, she is fully
oriented, and her range of affect is full. Which of
the following is
the most likely diagnosis?

A
) Adjustment disorder with anxiety

B
) Adjustment disorder with depressed mood

C
) Dysthymic disorder

D
) Generalized anxiety disorder

E
) Major depressive disorder

F
) Panic disorder with agoraphobia

G
) Post-traumatic stress disorder

7. A 65-year-old woman has a 6-month history of
progressive
irritability, palpitations, heat intolerance, frequent
bowel movements, and a
6.8-kg (15-lb) weight loss. She has had a neck mass
for more than 10
years. 131I scan shows an enlarged thyroid gland with
multiple areas of
increased and decreased uptake. Which of the
following is the most
likely diagnosis?

A
) Defect in thyroxine (T4) biosynthesis

B
) Graves' disease

C
) Multinodular goiter

D
) Riedel's thyroiditis

E
) Thyroid carcinoma

F
) Thyroiditis

G
) Toxic adenoma

H
) Triiodothyronine (T3) thyrotoxicosis

A
) Acute gastrointestinal bleeding

B
) Adrenal insufficiency

C
) Aortic valve rupture

D
) Cardiac tamponade

E
) Congestive heart failure

F
) Pneumonia

G
) Pulmonary embolism

H
) Sepsis

8. A previously healthy 62-year-old man is brought
to the emergency
department by paramedics 40 minutes after the sudden
onset of severe
shortness of breath while dressing this morning. He
is unable to provide
additional medical history. He is in severe
respiratory distress. His
temperature is 37.8 C (100 F), blood pressure is 90/60
mm Hg, pulse is
120/min and regular, and respirations are 24/min.
Examination shows
marked jugular venous distention. The lungs are clear
to auscultation.
Cardiac examination shows a nondisplaced and discrete
point of maximal
impulse and normal S1 and S2; there is an S4 and a
right parasternal
heave. Abdominal examination shows no abnormalities.
There is no edema
of the lower extremities. Laboratory studies show:

Hematocrit 40%
Leukocyte count 14,000/mm3
Platelet count 350,000/mm3

Arterial blood gas analysis on 5 L/min of oxygen:

pH 7.5
PCO2 16 mm Hg
PO2 64 mm Hg

A previously healthy 67-year-old woman is brought to
the emergency
department by paramedics 40 minutes after the sudden
onset of shortness of
breath while shopping. She is unable to provide
additional medical
history. She is in severe respiratory distress. Her
temperature is 37 C
(98.6 F), blood pressure is 90/60 mm Hg, pulse is
120/min and regular,
and respirations are 24/min. Examination shows marked
jugular venous
distention. Diffuse crackles are heard throughout all
lung fields.
Cardiac examination shows an enlarged point of maximal
impulse and normal
S1 and S2; there is an S3. Abdominal examination
shows no
abnormalities. There is no edema of the lower
extremities. Laboratory studies
show:

Hematocrit 38%
Leukocyte count 12,000/mm3
Platelet count 350,000/mm3

Arterial blood gas analysis on 5 L/min of oxygen:

pH 7.5
PCO2 16 mm Hg
PO2 64 mm Hg

10. A mentally competent 76-year-old man is in the
terminal stage of
multiple myeloma. He is unable to move and requires
24-hour nursing
care. Increasing doses of narcotics are needed to
control severe pain.
As a result, when he is pain-free, respiratory
function is impaired and
consciousness is clouded. The patient says he cannot
live with this
degree of pain and asks to be given a lethal injection
of pain
medication. Which of the following is the most
appropriate step regarding the
pain medication?

C
) Administer the dosage necessary to control pain
and add a
centrally acting stimulant

D
) Appeal to the family to convince the patient to
tolerate a bit
more pain

11. A 2-day-old newborn is brought to the physician
because of a
generalized rash for 6 hours. The newborn is active,
alert, and feeding
well. His temperature is 36.9 C (98.4 F).
Examination shows a rash
consisting of numerous white and pale yellow papules
with a large base of
macular erythema over the trunk and extremities.
Wright's stain of
scrapings from the lesions shows eosinophils. Which
of the following is
the most appropriate next step in management?

A
) Reassurance

B
) Topical corticosteroid therapy

C
) Intravenous acyclovir therapy

D
) Intravenous ampicillin and gentamicin therapy

E
) Intravenous nafcillin therapy

12. A 4-year-old boy is brought for a well-child
examination. He
uses two-word phrases, can say his first name but not
his last name, and
cannot identify colors. He is just beginning toilet
training. His
7-year-old sister has a learning disability and
attends special education
classes. Genital development is Tanner stage 1;
testes are large.
Which of the following is the most appropriate next
step in diagnosis?

A
) Reexamination in 6 months

B
) Thyroid function tests

C
) DNA testing

D
) Measurement of bone age

E
) CT scan of the head

3. A 72-year-old man is brought to the physician
because of a 2-day
history of nausea and vomiting. The vomitus has been
clear, and no
blood has been noted. He has had a decreased appetite
for the past week.
There is no associated pain or altered bowel function.
He reports that
he is not seeing things correctly. He takes warfarin
and digoxin for
atrial fibrillation, hydrochlorothiazide for
hypertension, and potassium
supplements that he discontinued 3 weeks ago when he
ran out of
tablets. His temperature is 37 C (98.6 F), blood
pressure is 144/88 mm Hg,
and pulse is 52/min and irregular. Bowel sounds are
normal. The abdomen
is soft and nontender without rebound or guarding. No
organomegaly or
masses are palpated. Which of the following is the
most likely
diagnosis?

A
) Acute pancreatitis

B
) Brain tumor

C
) Diabetic gastroparesis

D
) Diabetic ketoacidosis

E
) Drug toxicity

F
) Food poisoning

G
) Gastric bezoar

H
) Gastric carcinoma

I
) Pyloric channel ulcer

J
) Small-bowel obstruction

K
) Uremia

14. A 27-year-old primigravid woman at 12 weeks'
gestation comes to
the emergency department 2 hours after the sudden
onset of bright red
vaginal bleeding. She has not had abdominal cramping.
Pelvic
examination shows a small amount of brownish blood in
the posterior fornix of
the vagina. The cervix is closed. The uterus is
palpable 3 cm above the
pelvic brim. Fetal heart tones are easily audible at
167/min by
Doppler. Which of the following is the most likely
diagnosis?

A
) Abruptio placentae

B
) Ectopic pregnancy

C
) Incomplete abortion

D
) Placenta previa

E
) Threatened abortion

F
) Normal pregnancy

15. A 72-year-old man is brought to the physician
by his son because
of a 4-day history of increasing confusion and memory
problems. The
son says that his father's ability to function
independently has been
generally declining over the past few years, and he
has become much more
impaired over the past week. The patient has had at
least three to four
previous episodes of a sudden decline of cognitive
functioning over the
past 3 years without full recovery. He has a history
of hypertension.
His blood pressure is 160/95 mm Hg without orthostatic
changes.
Neurologic examination shows no focal findings.
Mini-Mental State Examination
score is 21/30. Which of the following is the most
likely underlying
pathophysiologic process?

A
) Central nervous system demyelination

B
) Central nervous system infection

C
) Diffuse axonal injury

D
) Diffuse cortical atrophy

E
) Left temporal lobe infarction

F
) Multiple, small, central nervous system
infarctions

G
) Subdural hematoma

16. A 72-year-old woman comes for a routine health
maintenance
examination. She has a 3-year history of occasional
loss of small amounts
of urine when she coughs or sneezes. She has had no
pain or burning
with urination. She has hypertension treated with
daily
hydrochlorothiazide. She underwent an appendectomy at
the age of 10 years. She has
three children and had uncomplicated pregnancies.
Examination shows no
abnormalities except for a moderate cystocele. Which
of the following is
the most likely cause of this patient's urinary
symptoms?

A
) Chronic infectious trigonitis

B
) Large intravesical calculus

C
) Obstetric trauma

D
) Polycystic kidney disease

E
) Spastic neurogenic bladder

17. A 47-year-old woman is brought to the emergency
department by
her husband because of hallucinations and agitation
for 6 hours. She has
a 10-year history of alcoholism. Her last alcoholic
drink was 48 hours
ago. She is agitated and inattentive. Her
temperature is 38.3 C (101
F), blood pressure is 190/120 mm Hg, and pulse is
110/min. She is
oriented to person but not to place or time. During
the examination, she
shrieks, "Make the lizards go away." Which of the
following is the most
appropriate initial step in management?

A
) Electroencephalography

B
) CT scan of the head

C
) Intravenous ampicillin therapy

D
) Intravenous haloperidol therapy

E
) Intravenous lorazepam therapy

18. A 27-year-old woman comes to the physician
because of a 3-week
history of fever, night sweats, rash on both legs,
nonproductive cough,
and pain and swelling in her wrists and knees. She
has not had weight
loss. Her temperature is 37.7 C (99.8 F), blood
pressure is 110/70 mm
Hg, pulse is 96/min, and respirations are 14/min. The
lungs are clear
to auscultation. Cardiac examination shows no
abnormalities. There is
swelling and warmth over the wrists and knees
bilaterally and tender
red nodules on the anterior surface of both lower
extremities. An x-ray
film of the chest shows bilateral hilar fullness.
Which of the
following is the most likely diagnosis?

A
) Carcinoma of the lung

B
) Histoplasmosis

C
) Hodgkin's disease

D
) Sarcoidosis

E
) Tuberculosis

19. A 52-year-old woman comes to the physician
because of difficulty
climbing stairs for 4 months. She has also noted that
her thighs hurt
when she presses on them. She has had increasing
difficulty combing
her hair because she tires easily. On examination,
she pushes herself
out of the chair with her arms. There is weakness of
the proximal
muscles of the extremities. Which of the following is
the most likely
diagnosis?

A
) Cauda equina syndrome

B
) Cerebellar degeneration

C
) Cervical spinal cord compression

D
) Diabetic polyneuropathy

E
) Femoral artery insufficiency

F
) Guillain-Barré syndrome

G
) Lumbar spinal stenosis

H
) Multiple sclerosis

I
) Normal-pressure hydrocephalus

J
) Polymyositis

K
) Sensory neuropathy

L
) Tabes dorsalis

20. A 72-year-old man comes to the physician
because of generalized
weakness and night sweats for 6 months. During this
period he has had
a 5-kg (11-lb) weight loss. He has had polycythemia
vera for 12 years
treated with hydroxyurea and multiple phlebotomies.
Examination shows
cachexia. The liver is enlarged and nontender with a
span of 13 cm;
the spleen is enlarged. Hematocrit is 27%, leukocyte
count is 3200/mm3,
and platelet count is 150,000/mm3. A blood smear is
shown. Which of
the following is the most likely diagnosis?

A
) Acute myelogenous leukemia

B
) Cirrhosis of the liver

C
) Hodgkin's disease

D
) Miliary tuberculosis

E
) Myelofibrosis

21. A 30-year-old man has had increasingly severe
low back pain
since lifting a heavy object at work 3 days ago. The
pain does not radiate
and is not associated with bowel or bladder problems.
He has a history
of occasional stiffness and mild pain in his lower
back. There is
bilateral paravertebral muscle tenderness in the
lumbar region and limited
flexion of the lumbosacral spine. Examination of the
lower extremities
shows normal muscle strength and sensation;
straight-leg raising is
negative bilaterally. Deep tendon reflexes at the
knees and ankles are
normal. Which of the following is the most
appropriate next step in
management?

A
) Exercises to strengthen abdominal muscles

B
) Exercises to strengthen paravertebral muscles

C
) Bed rest for 5 to 7 days

D
) Use of a muscle relaxant

E
) Use of a nonsteroidal anti-inflammatory drug

22. A 42-year-old woman, gravida 2, para 2, has had
increasing
fatigue, dyspnea, orthopnea, and paroxysmal nocturnal
dyspnea over the past
2 days. She has had several episodes of hemoptysis;
she had one
episode of pulmonary edema during pregnancy 2 years
ago. A loud S1, a
snapping sound in diastole, and a rumbling diastolic
murmur are heard at the
apex. Which of the following is the most likely cause
of her
condition?

A
) Atrial myxoma

B
) Bicuspid aortic valve

C
) Postpartum cardiomyopathy

D
) Rheumatic heart disease

E
) Viral myocarditis

3. A 37-year-old woman has had unilateral breast
pain, fever, and
chills for 24 hours. She breast-feeds her 1-month-old
newborn. Her
temperature is 38 C (100.4 F). Examination shows
swelling, erythema, and
localized tenderness of the left breast. Which of the
following is the
most appropriate next step in management?

A
) Application of ice packs to the affected breast

B
) Use of a breast pump

C
) Immediate discontinuation of breast-feeding

D
) Bromocriptine therapy

E
) Penicillinase-resistant antibiotic therapy

24. A 19-year-old woman, gravida 2, para 1, at 39
weeks' gestation
is admitted in labor. Contractions occur every 2 to 3
minutes. The
cervix is 4 cm dilated and 80% effaced. She requests
an epidural for pain
control. Ten minutes after the epidural is
administered, she becomes
nauseated and diaphoretic and vomits. Her blood
pressure is 60/palpable
mm Hg. A fetal heart tracing shows sustained fetal
decelerations. The
cervix is now 8 cm dilated. The most appropriate next
step in
management is administration of which of the
following?

A
) Ephedrine

B
) Magnesium sulfate

C
) Nifedipine

D
) Oxytocin

E
) Terbutaline

25. An asymptomatic 47-year-old man comes for a
routine follow-up
examination 3 weeks after sustaining an inferior wall
myocardial
infarction. His recovery was complicated by transient
premature ventricular
contractions during the first 2 days of
hospitalization. An exercise
stress test prior to discharge showed no pain at 70%
of his predicted
maximum exercise capacity. Medications include daily
aspirin and
pravastatin. His blood pressure is 136/80 mm Hg,
pulse is 80/min and regular,
and respirations are 16/min. Cardiopulmonary
examination shows no
abnormalities. Which of the following is the most
appropriate additional
pharmacotherapy for this patient?

A
) Clonidine

B
) Metoprolol

C
) Quinidine

D
) Sulfinpyrazone

E
) Verapamil

26. A 35-year-old woman is brought to the emergency
department by
her family because of shortness of breath, tightness
in her chest, and
palpitations for 2 hours. Over the past 11 months,
she has had five
similar episodes; during the last episode 3 weeks ago,
she was treated with
an intravenous medication that caused conversion to
sinus rhythm. Her
blood pressure is 95/60 mm Hg, and pulse is 165/min
and regular. The
lungs are clear to auscultation. Which of the
following is the most
likely underlying dysrhythmia?

A
) Accelerated idioventricular rhythm

B
) Accelerated junctional rhythm

C
) Atrial fibrillation

D
) Multifocal atrial tachycardia

E
) Normal sinus rhythm

F
) Paroxysmal supraventricular tachycardia

G
) Premature supraventricular beats

H
) Premature ventricular beats

I
) Sick sinus syndrome

J
) Sinus bradycardia

K
) Sinus tachycardia

L
) Ventricular fibrillation

M
) Ventricular tachycardia

27.

A 4-year-old boy is brought to the emergency
department because of a
1-day history of fever and increasing difficulty
breathing. Over the
past year, he has had recurrent bacterial infections
including cervical
lymphadenitis, septic arthritis, and pneumonia. His
temperature is 38.9
C (102 F), blood pressure is 80/60 mm Hg, pulse is
115/min, and
respirations are 38/min and labored. Breath sounds
are decreased over the
left anterior chest. Scattered crackles are heard on
auscultation. A
thoracentesis shows purulent fluid. Laboratory
studies show:

Nitroblue tetrazolium test is abnormal. A Gram's
stain of the pleural
fluid shows numerous gram-positive cocci in the
segmented neutrophils.
An x-ray film of the chest shows left lower lobe
pneumonia with pleural
effusion. The most likely cause of this patient's
symptoms is a defect
of which of the following?

A
) Chemotaxis

B
) Immotile cilia

C
) Opsonization

D
) Phagocytic oxidative metabolism

E
) Phagocytosis

F
) T-lymphocyte function

28. A 59-year-old woman comes to the emergency
department 45 minutes
after the onset of chest discomfort that is not
relieved by three
nitroglycerin tablets. Over the past 3 months, she
has had similar episodes
characterized by nonradiating pain and a feeling of
heaviness; the
episodes were exacerbated by exertion or heavy meals
and were slowly
relieved by rest. Sublingual nitroglycerin has
provided rapid relief of
symptoms in the past. She has hypercholesterolemia,
type 2 diabetes
mellitus, and peptic ulcer disease. She smoked two
packs of cigarettes daily
for 25 years but quit 5 years ago. She appears
anxious and diaphoretic
and is nauseated. Examination shows no other
abnormalities except for
an S4. Which of the following is the most likely
diagnosis?

A
) Acute aortic dissection

B
) Angina pectoris

C
) Esophageal spasm

D
) Myocardial infarction

E
) Pulmonary embolism

29. A 27-year-old woman comes to the physician
because of
increasingly severe daily headaches over the past 3
months. The headaches are
diffuse and often occur at the base of the skull. For
the past month,
she has had brief episodes of visual darkening when
standing. She has
been amenorrheic for the past year and has had an
18-kg (40-lb) weight
gain during this period. She now weighs 118 kg (260
lb) and is 152 cm
(60 in) tall. Funduscopic examination shows
papilledema, several flame
hemorrhages, and an enlarged blind spot bilaterally.
Visual acuity is
20/20 bilaterally. A CT scan of the head shows no
abnormalities. Which
of the following is the most likely underlying cause
of these findings?

A
) Cerebral venous occlusion

B
) Communicating hydrocephalus

C
) Cytotoxic edema

D
) Idiopathic intracranial hypertension

E
) Impaired absorption of cerebrospinal fluid

F
) Infratentorial mass lesion

G
) Interstitial edema

H
) Overproduction of cerebrospinal fluid

I
) Vasogenic edema

30. A 75-year-old man with a 3-year history of
progressive cognitive
impairment due to dementia, Alzheimer's type, has had
nocturnal
disorientation for 2 weeks. He lives at home with his
wife. He is otherwise
healthy and takes no medications. Physical
examination shows normal
findings. He is disoriented to time and place, has
poor short-term
memory, is unable to do simple arithmetic, and has a
poor understanding of
general information. Which of the following is the
most appropriate
initial step in management?

A
) Increase in home nighttime lighting

B
) Prescription for chloral hydrate

C
) Prescription for diazepam

D
) Prescription for haloperidol

E
) Use of nighttime mechanical restraints

31. A 62-year-old woman comes to the physician
because of severe
pain and swelling of her right knee for 1 day. She
has no history of
joint disease or trauma to the knee. She has
hypertension treated with
hydrochlorothiazide and type 2 diabetes mellitus
treated with glyburide.
She is sexually active only with her husband, and they
have sexual
intercourse one to two times each week. Her
temperature is 37 C (98.6 F),
blood pressure is 140/84 mm Hg, and pulse is 80/min.
Examination of
the right knee shows edema, erythema, and exquisite
tenderness to light
touch; there is an effusion. The remainder of the
examination shows no
abnormalities. Which of the following is the most
likely mechanism of
these findings?

A
) Immune complex deposition

B
) Inflammatory reaction to antisynovial antibodies

C
) Inflammatory reaction to monosodium urate
crystals

D
) Neisseria gonorrhoeae infection

E
) Streptococcus pneumoniae infection

32. Two days after a cholecystectomy, a 42-year-old
woman has
shortness of breath. Her temperature is 37.5 C (99.5
F), blood pressure is
110/70 mm Hg, pulse is 103/min, and respirations are
24/min. There is
abdominal tenderness. Examination shows no other
abnormalities. An
x-ray film of the chest shows minimal linear markings
in the right lower
lobe. Arterial blood gas analysis on 45% oxygen
shows:

pH 7.41
PCO2 40 mm Hg
PO2 52 mm Hg

Which of the following is the most likely explanation
for her hypoxia?

A
) Acute respiratory distress syndrome

B
) Atelectasis

C
) Congestive heart failure

D
) Fat embolism syndrome

E
) Pneumonia

F
) Pneumothorax

33. A 37-year-old woman comes to the emergency
department because of
a 3-day history of increasingly severe abdominal pain,
nausea, and
vomiting. Twelve years ago, she had a hysterectomy
because of severe
dysfunctional uterine bleeding. Her temperature is 37
C (98.6 F), blood
pressure is 106/70 mm Hg, pulse is 110/min, and
respirations are 12/min.
Examination shows a distended, tympanic abdomen with
diffuse tenderness
but no guarding; bowel sounds are hypoactive. Her
leukocyte count is
10,000/mm3, and hematocrit is 44%. An x-ray film of
the abdomen is
shown. Which of the following is the most appropriate
initial step in
management?

A
) CT scan of the abdomen

B
) Intravenous neostigmine therapy

C
) Esophagogastroduodenoscopy

D
) Nasogastric intubation

E
) Laparotomy

34. A healthy 27-year-old woman comes for a routine
health
maintenance examination. Her blood pressure is 185/90
mm Hg. Examination shows
no other abnormalities except for hypertensive
retinopathy. Serum
studies show a sodium level of 140 mEq/L, potassium
level of 4 mEq/L, and
creatinine level of 1.1 mg/dL. A complete blood
count, serum
catecholamine levels, and urinalysis are within normal
limits. At two subsequent
visits, her blood pressure is 190/100 mm Hg and 182/96
mm Hg,
respectively. Which of the following is the most
appropriate next step in
diagnosis?

A
) 24-Hour urine collection for measurement of
creatinine clearance

B
) 24-Hour urine collection for measurement of
17-hydroxycorticosteroid and total 17-ketosteroid
levels

C
) Measurement of serum aldosterone level

D
) Magnetic resonance angiography of renal vessels

E
) CT scan of the abdomen

35. A 76-year-old man has had fatigue and loss of
interest in daily
activities over the past 4 months. He sleeps poorly
and has had a
4.5-kg (10-lb) weight loss during this period. He
states that he has
probably lived long enough. His blood pressure is
110/78 mm Hg, and pulse
is 68/min. Examination shows a slow return of deep
tendon reflexes.
Measurement of which of the following serum levels is
the most
appropriate next step in management?

A
) Calcium

B
) Creatinine

C
) Glucose

D
) Testosterone

E
) Thyroid-stimulating hormone

36. A 29-year-old woman is brought to the physician
by her father.
She has been working continuously without sleep for 3
days on a project
which she claims "Allah and Jesus have told me to do"
that will "unify
all knowledge in physics and medicine and philosophy."
She hears the
voice of her dead brother telling her that she will be
"the next Virgin
Mary." Her father states that she was treated for
depression for 1 year
at the age of 19 years. Which of the following is the
most likely
diagnosis?

A
) Bipolar disorder

B
) Borderline personality disorder

C
) Major depressive disorder

D
) Schizophrenia

E
) Substance-induced mood disorder

37. A 67-year-old man is hospitalized for treatment
of renal
insufficiency. Three days after admission, his pulse
is 40/min. An ECG shows
tall, tented T waves. Serum studies show a sodium
level of 134 mEq/L,
potassium level of 6.9 mEq/L, and glucose level of 85
mg/dL. The most
appropriate next step in management is intravenous
administration of
which of the following?

A
) Calcium, furosemide, and 3% saline

B
) Calcium, insulin, and digitalis

C
) Calcium, insulin, and glucose

D
) Glucose, furosemide, and phosphate

E
) Glucose, glucagon, and bicarbonate

38. Six months after the delivery of her fourth
child, a 37-year-old
woman undergoes laparoscopic tubal ligation. Menses
occur at regular
28-day intervals. During the operation, she is found
to have a small
dark lesion in the cul-de-sac and filmy adhesions
surrounding the
ovaries. A biopsy specimen of a cul-de-sac lesion
confirms the diagnosis of
endometriosis. Which of the following is the most
appropriate next step
in management?

A
) Danazol therapy

B
) Gonadotropin-releasing hormone agonist therapy

C
) Oral contraceptive therapy

D
) Total abdominal hysterectomy and bilateral
salpingo-oophorectomy

E
) No further treatment indicated

A
) Administration of parenteral antibiotics

B
) Admission to the hospital for medical management

C
) Admission to the hospital for operative
management

D
) Colon contrast studies

E
) Discharge for follow-up by personal physician

F
) Endoscopy

G
) MRI of the abdomen

H
) Observation in the emergency department

39. A previously healthy 6-month-old boy is brought
to the emergency
department because of a 12-hour history of
intermittent episodes of
inconsolable crying associated with drawing up of the
legs. Over the past
6 hours, he has had intermittent diarrhea that is
reddish and mucoid,
and for the past 3 hours he has been somnolent. On
examination, he is
sleepy but arousable. His temperature is 38.1 C
(100.6 F), blood
pressure is 90/55 mm Hg, pulse is 140/min, and
respirations are 38/min. He
cries when his abdomen is palpated; a mass is felt in
the right lower
quadrant. His leukocyte count is 12,400/mm3 (50%
segmented neutrophils,
8% bands, 1% eosinophils, 40% lymphocytes, and 1%
monocytes). Serum
electrolyte levels are within normal limits. An x-ray
film of the
abdomen shows no free air.

A
) Administration of parenteral antibiotics

B
) Admission to the hospital for medical management

C
) Admission to the hospital for operative
management

D
) Colon contrast studies

E
) Discharge for follow-up by personal physician

F
) Endoscopy

G
) MRI of the abdomen

H
) Observation in the emergency department

40. A previously healthy 14-year-old girl is
brought to the
emergency department because of abdominal pain for 12
hours. She has a 1-week
history of brownish vaginal discharge. Menarche was
at the age of 12
years, and her periods have occurred at regular 28-day
intervals over
the past year. Her last menstrual period was 7 weeks
ago. Her
temperature is 37 C (98.6 F), blood pressure is 85/55
mm Hg, pulse is 145/min,
and respirations are 24/min. Abdominal examination
shows generalized
tenderness, and there is guarding with rebound in the
right lower
quadrant. Her hematocrit is 24%, and leukocyte count
is 9400/mm3 (60%
segmented neutrophils, 3% bands, 1% eosinophils, 35%
lymphocytes, and 1%
monocytes). Serum electrolyte levels are within
normal limits.

41. A 49-year-old woman is admitted to the hospital
because of renal
failure. She has had episodes of flank pain over the
past 20 years.
She has also had nocturia 2 to 3 times nightly for 10
years. Her blood
pressure is 160/100 mm Hg. Examination shows pale
mucous membranes. A
mass is palpated in the right flank. Which of the
following is the
most likely diagnosis?

A
) Horseshoe kidney

B
) Nephrolithiasis

C
) Papillary necrosis

D
) Polycystic kidney disease

E
) Renal cell carcinoma

42. On routine annual screening, an asymptomatic
27-year-old man has
a positive PPD skin test. One year ago, a PPD skin
test was negative.
He works as a nurse. Three years ago, he was
diagnosed with hepatitis
A after a trip to South America. Examination shows no
abnormalities.
His serum aspartate aminotransferase (AST, GOT)
activity is 10 U/L, and
serum alanine aminotransferase (ALT, GPT) activity is
14 U/L. An x-ray
film of the chest shows no abnormalities. Which of
the following is
the most appropriate chemoprophylaxis?

A
) Isoniazid and folic acid supplementation

B
) Isoniazid and rifampin

C
) Isoniazid and vitamin B1 (thiamine)
supplementation

D
) Isoniazid and vitamin B6 supplementation

E
) No prophylaxis indicated

43.

A 4-month-old boy is brought to the physician because
of a 2-day
history of fever and progressive redness around his
right eye. He has had
persistent diarrhea and oral candidiasis since birth
and was treated for
pneumococcal pneumonia at the age of 2 months. He
appears ill. His
temperature is 39 C (102.2 F), pulse is 130/min, and
respirations are
25/min. Examination shows violaceous preseptal
(periorbital) cellulitis
and oral candidiasis. Laboratory studies show:

44. One week after undergoing an uncomplicated
liver transplant for
biliary atresia, a 3-year-old boy appears jaundiced.
Examination shows
scleral icterus. His serum aspartate aminotransferase
(AST, GOT)
activity has increased to 1300 U/L, and serum alanine
aminotransferase (ALT,
GPT) activity has increased to 2500 U/L. His serum
bilirubin level is
3.5 mg/dL, and serum alkaline phosphatase activity is
100 U/L. Which
of the following is the most likely artery responsible
for this
patient's gastrointestinal symptoms?

A
) Hepatic

B
) Ileocolic

C
) Inferior mesenteric

D
) Left gastric

E
) Left gastroepiploic

F
) Middle colic

G
) Posterior penetrating

H
) Right colic

I
) Right gastroepiploic

J
) Splenic

K
) Superior hemorrhoidal

L
) Superior mesenteric

45. A 2-year-old girl has had fever and bloody
diarrhea for 10 days.
A stool culture obtained 7 days ago grew Salmonella
species sensitive
to amoxicillin. A blood culture was negative.
Despite beginning oral
amoxicillin therapy 4 days ago, her diarrhea has
persisted. Current
examination shows no other abnormalities except for a
temperature of 38.6 C
(101.5 F). Which of the following is the most likely
explanation for
the failure of amoxicillin to improve her symptoms?

A
) Amoxicillin does not alter the course of
Salmonella enteritidis

B
) Amoxicillin has caused pseudomembranous colitis

C
) Amoxicillin is absorbed at the level of the
jejunum, leaving no
drug to be delivered to the colon

D
) Oral amoxicillin is not absorbed into the
systemic circulation in
the presence of diarrhea

A 23-year-old man comes to the physician because of a
1-month history
of intermittent right-sided abdominal pain, nausea,
and vomiting. He
has sickle cell disease and has been treated several
times for painful
crises. Examination of the abdomen shows tenderness
to palpation of the
right upper quadrant on inspiration. Laboratory
studies show:

2) u put acast for a pt, 2 days later he wants u to pull it up,the pts is agitated with alcohol smell in his mouth.when u asked him if he drives the car to u, he got anger and said:"if don't pull the cast i will hurt u" and he broke the chair.
next step ?
a- call the security
b- pull the cast
c- arrest him

13) after ERCP for a stone in the common duct,there is hi amylase + abdominal distention.
Dx?
a-pancreatitis due to ERCP .
b- duodenal perforation
c- gastric perforation
d- cholangitis

14) woman with coma (due to trauma ), her friend brought her to ER with a paper says that the pts doesn't want heroic efforts in treating her.but the durable power attorney is with pt's sister.
what will u do now?
a-treat
b- don't treat due to paper
c- call pt's sister
(what if her freind told u that the pt wrote a paper for not to give heroic effort in treating her ,nd the paper with pt's sister)

15)65 man with ALS tells u not to tell his family(children) about that.
what do u do ?
a-tell them
b-don't tell them (keeping the confidently)
c- u should tell them and look for ALS gene.

22)mi,6 weeks later he got colon resection, the day after surgery he felt compressive chest pain.
explanation?

23)child with upper tibial mass,nontender,immobile,not erythematous, no tenderness.X-ray:the bone is NL,
AND THE MASS OCCUPYING the tissue near the bone.
Dx?
a-osteosarcoma
b-osteochondroma
c-sarcoma of soft tissue

** Dx is best confirmed with?
A- LP
B- Doppler US of carotid artries
C- Head MRI
D- Head CT followed by cerebral angiography
E- EEG

** What’s the next most important step in Mx?
A- urgent surgery with aneurysm clipping
B- admission to ICU, close monitoring and Tx of HTN
C- admission to ICU, close monitoring and IV antibiotics
D- anticoagulation & antiplatlete therapy
E- serial LP to drain CSF

Answers are B, D, A
most likley the pt. ruptured cerebral anurysm, as pt. is confused, no focal signs present and pt. has nuchal rigidity, could be and most likely due to the blood in the CSF--> meningeal irritation, etc..
although you also see nuchal rigidity w/ meningitis, here you have confusion as well
although they give us a nice high B.P of 160/100, and we might want to choose stroke over cerebral anurysm, given the rest of the prez. here anurysm is more likly, as well as you would expect to see neuro focal findings w/ stroke, not present here
ischemic cerebrovascular accident --> expect to see some focal signs as well as may not have nuchal rigidity
TIA, usually transient and other symptoms present , not seen here

3- During an elective laparascopic cholecystectomy, the patient developes a sudden onset drop in BP, atrial desaturation and an increase in ventilatory pressure. What’s the most appropriate step of Mx?
A- an IV fluid bolous
B- decompression of the pneumoperitoneum
C- inserting a chest tube
D- re-evaluating the position of the endotracheal tube & portable CXR
E- aborting the procedure & converting to an open cholecystectomy

Answer is E & B. because he’s at high risk of infection, especially with encapsulated organisms and penicillin will dramatically decrease this risk. Pneumococcal vaccine is not effective in neonates. It’s usually given at 2 yrs age.

Answer is D. low MCV is either IDA or beta-thal. BUT, high no. of RBCs is characteristic of beta-thal. In IDA, RBC count is below normal.
pt. has hypocromic, microcytic anemia,..as well as increased retic. count--> increased RBC's, ..this last feature makes the better choice here to be thalassemia, as oposed to iron def. for example
iron def. seems to be avery good choice, as one should think anemia in older MAN , is due to cancer-COLON ca , until proven otherwise..however you would expect to see low reticulocytes count w/ iron def. anemia.
note- elevated retic. counts--> seen in thalassemia/hemoglobinopathy,..like SS anemia

Answers are C & B. Acute monoarticular arthritis in association with linear calcification in the cartilage of knee maqkes the Dx of pseudogout which is positive for birefringent crystals in joint fluid. Pseudogout maybe associated with hemochromatosis.

9- A patient with low grade fever & weight loss has poor excursion on the Rt. side of chest with decreased fremitus, flatness to percussion and decreased breath sounds. Trachea is deviated to the Lt. What’s the most likely Dx?
A- Pneumothorax
B- Pleural effusion secondary to histoplasmosis
C- Consolidated pneumonia
D- Atelectasis

Answer is B. Physical findings all consistent with pleural effusion, which in large amount can shift trachea to the Lt. in pneumothorax hyperresonance of the affected side is present. Atelectasis on the Rt would shift trachea to the Rt.

10- A patient have an unexpected high value for diffusing capacity, this finding is most consistent with which of the ffg?
A- Anemia
B- Cystic fibrosis
C- Emphysema
D- Intrapulmonary hemorrhage

11- A 65 y/o man is admitted to the hospital with anginal chest pain. His general health has been excellent, although he has had a multinodular goiter for many years. He had a series of thyroid function tests 4 weeks before admission, and the results are :
Serum T4 8.0 µg/dL
Free T4 index 8.0
Serum T3 152 ng/dL
Serum thyrotropin (TSH) 0.7 µU/mL

A MI is ruled out, but chest pain continues. A coronary arteriogram shows a 90% stenosis of the left main coronary artery. A coronary artery bypass graft is done. The patient has an uneventful postoperative course and is discharged on the seventh postoperative day. One month later, he is readmitted in atrial fibrillation with a rapid ventricular response. Repeat thyroid function testing shows the following:
Serum T4 15.0 µg/dL
Free T4 index 15.8
Serum T3 220 ng/dL
Serum TSH <0.01 mU/µL

What is the most likely Dx?
A. Graves' disease
B. Stress-induced hyperthyroidism
C. Iodine-induced hyperthyroidism
D. Silent thyroiditis
Answer is C. The natural history of multinodular goiters is slow growth and gradual decrease in thyrotropin (TSH), reflecting increasing thyroid hormone production. This progression occurs over years to decades, however. Many patients with multinodular goiters have autonomous areas within their thyroid. This patient had normal thyroid function 1 month before admission. However, his serum TSH level was near the lower limits of normal, suggesting the possibility of autonomous thyroid function.
When patients with multinodular goiters are exposed to excess iodine, severe hyperthyroidism may occur. This is known as iodine-induced hyperthyroidism or the Jod-Basedow phenomenon. When iodine supplementation is introduced into areas of iodine deficiency, iodine-induced hyperthyroidism may occur in patients with multinodular goiters. Iodine-induced hyperthyroidism may occur in nonendemic goiter areas as well, often with devastating consequences.
The high iodine content of the dye used for the cardiac catheterization undoubtedly precipitated the hyperthyroidism in this patient. The onset of hyperthyroidism may be delayed for several weeks to months after the iodide exposure.
Although other causes of hyperthyroidism are possible, none is as likely as this scenario. When patients with multinodular goiter must be exposed to excess iodine (for example, during cardiac catheterization, computed tomographic [CT] scan with contrast medium, or amiodarone therapy), premedication with antithyroid drugs (methimazole or propylthiouracil) should be considered.

Answer is C. This is the classic description of primary biliary cirrhosis. Itching is the most common specific symptom of early primary biliary cirrhosis. Approximately 70% of affected patients have enlarged livers. The best screening test for suspected primary biliary cirrhosis is the antimitochondrial antibody test. It is positive in 95% of affected patients and has a 98% specificity if newer enzyme-linked immunosorbent assay (ELISA) tests are used. Serum protein electrophoresis might show a diffuse increase in immunoglobulins. However, this finding is nonspecific and may be found in many chronic liver diseases. Anti¬smooth-muscle antibody tests are positive in some patients with autoimmune chronic hepatitis. However, the test is nonspecific and not terribly useful. The sulfur colloid technetium liver-spleen scan is useful for detecting portal hypertension and hypersplenism. However, it is not specific and would not be helpful in diagnosing primary biliary cirrhosis. Endoscopic retrograde cholangiopancreatography (ERCP) is typically normal in patients with primary biliary cirrhosis. Its only role in the diagnosis of primary biliary cirrhosis is in the patient who presents with a similar syndrome but who has a negative antimitochondrial antibody test. ERCP would then be performed to look for other causes of disease such as primary sclerosing cholangitis.

13- A patient presents to your office with complaints of severe earache and decreased hearing on the left side. Examination confirms left otitis media. You prescribe an oral cephalosporin and an analgesic. The next day the patient is brought to the emergency room with a rash and moderate bronchospasm. Reviewing his office record you are horrified to discover that he is known to have a severe allergic reaction to penicillin.
What should you tell the patient at this point?
(A) Apologize and explain what happened.
(B) Apologize and offer to compensate him financially.
(C) Attribute the rash and the bronchospasm to his infection.
(D) Explain to the patient that he is allergic to cephalosporin as well as penicillin.
(E) No explanations are necessary.
Answer is A. Medical errors are common but are infrequently reported to patients. The fear is that acknowledging a mistake may lead to litigation. Nevertheless, there is no excuse for a physician not to admit a mistake, which is an inevitable part of medical practice. Apologizing and explaining is not only ethical, but also has been shown to decrease the risk of litigation. There is no need or obligation to offer financial compensation. Trying to attribute your mistake to other causes, or attempting to blame the patient for your negligence is not only unethical, but will increase your risk of litigation. Finally, nothing will anger a patient more than no explanation at all.

14- A 29 y/o woman presents with an exacerbation of her asthma. She is 11 weeks pregnant. She has mild intermittent asthma and usually takes a ß-agonist as needed. She has one 4-year-old child who is in day care and has had a recent upper respiratory tract infection. She has a dry cough, clear nasal discharge, myalgias, and fatigue.
On physical examination, she is talking in full sentences and has normal tympanic membranes, mildly erythematous oropharynx without exudates, no adenopathy; she has positive wheezing bilaterally. The peak flow is 300 mL; her usual result is 390 mL. Pulse oximetry is 93% on room air.Which of the following is indicated in the management of this patient?
(A) Amoxicillin
(B) Theophylline
(C) Prednisone
(D) Montelukast
(E) Flunisolide
Answer is E. Treatment principles for asthma in the nonpregnant patient apply also to the pregnant patient. She has mild intermittent asthma with an exacerbation, for which therapy with an inhaled glucocorticoid is an appropriate choice. Use of inhaled glucocorticoids is safe in pregnancy.
Asthma in pregnancy has a variable course, with one third of patients getting better, one third getting worse, and one third staying the same. This patient has had mild symptoms and now has an exacerbation related either to an upper respiratory tract infection, or to worsening of her asthma because of her pregnancy. She has no signs of streptococcal pharyngitis, sinusitis, bacterial tracheobronchitis, or pneumonia; antibiotics should therefore not be given. Prednisone therapy should be reserved for further symptoms. Theophylline can be used in pregnancy with close monitoring, but it is not the next drug of choice. Montelukast may be used in pregnancy, but should be reserved for progressive symptoms.
The patient should continue therapy with ß-agonists. Use of a peak flow meter at home is integral to her management; she should be instructed and encouraged in its use.

15- A 30-year-old woman presents because of 6 months of amenorrhea. She had regular menses starting at age 13 years and is otherwise healthy. Menses gradually became irregular over the past 5 years, in spite of relatively stable weight and activity. She has no acne or hirsutism. The results of recent laboratory tests included normal serum thyroid-stimulating hormone and prolactin levels and a negative serum pregnancy test.
What is the next most useful diagnostic test for the evaluation of secondary amenorrhea in this patient?
(A) Measurement of LH
(B) Measurement of FSH
(C) Pelvic US
(D) Measurement of serum estradiol
(E) MRI of the pituitary gland
Answer is B. In this patient, the negative pregnancy test, and normal serum TSH and prolactin levels exclude the most common causes of secondary amenorrhea. The remaining causes include hypothalamic amenorrhea and ovarian failure. Of the tests listed, serum FSH is the most likely to be diagnostic of a reproductive endocrine abnormality, as it has a longer half life than luteinizing hormone and becomes elevated relatively early in the process of ovarian aging. Luteinizing hormone is less useful because of its greater variability across the normal menstrual cycle (including the dramatic, often 10-fold, increase at the mid-cycle surge), its more striking 1 to 2 hourly pulsatility, and its elevation in polycystic ovary syndrome as well as ovarian failure. Serum estradiol is frequently in the normal range in various reproductive disorders and therefore rarely useful. MRI of the pituitary gland is not indicated unless other tests are normal and a hypothalamic cause of amenorrhea needs to be ruled out. Finally, pelvic ultrasound can show the presence of ovaries, their size, and the uterine morphology and endometrial thickness, but cannot diagnose the cause of secondary amenorrhea. It may be more useful in the evaluation of primary amenorrhea, if the physical examination is inadequate to confirm the presence of intact ovaries and a uterus, or in the evaluation of excessive menstrual bleeding, when it can identify endometrial thickening, polyps, and/or uterine leiomyomas. A medroxyprogesterone challenge test can show that the uterine anatomy and vaginal outflow track are normal, which is suggested by the history of previously normal menstrual cycles. In addition, the challenge test provides some information about recent estrogen exposure. However, it cannot be diagnostic in estrogen deficiency.

16- A 2 y/o has a chronic cough. CXR reveals hyperinflation of the left hemithorax. Bilateral decubitus views showed that the right lung becomes appropriately atelectatic however, the left side shows no change in appearance with decubitus positioning. What’s the most likely diagnosis?

Asymmetric hyperinflation suggests the possibility of an aspirated foreign body in this two year old infant. These findings suggest the diagnosis of an aspirated foreign body or a possible obstruction of the left main stem bronchus from a central etiology. Bronchoscopy is both diagnostic and therapeutic.

Aswers are B & B. There’s no clinical evidence of prerenal azotemia, so the most likely Dx is ATN due to toxicity with aminoglycoside. Urine sediment in ATN is abnormal and shows renal tubular epithelial cells, debris & muddy brown casts. Since patient has been getting diuretics, high urine Na is less specific.

19- 70 y/o man with Hx of COPD, presents with worsening SOB of the last couple days. He’s coughing yellow-colored sputum and gets no result from his beta 2 agonist & ipratropium aerosolized pumps. On P/E, RR=40, HR=110, BP= 155/85, he’s afebrile and using his accessory muscles for respiration. Also inspiratory & expiratory diffuse wheezing on both sides of his lungs are heard. What’s the most likely Dx?
A- Acute exacerbation of COPD
B- Alfa-1 antitrypsin def.
C- Chronic bronchitis
D- Exacerbation of asthma
E- Pneumonia
Answer is A- Acute exacerbation of COPD, it occurs when patient develops acute onset of marked dyspnea & tachypnea with use of accessory mucles with no response to medication.

21- A 5 y/o presents to the ER 3 h after a possible button battery ingestion. The patient is in no acute distress, vital signs are stable, and examination is benign. CXRshows what appears to be a small button battery in the stomach. Which of the following is the MOST appropriate next action?
(A) Upper GI series to further delineate the exact location of the foreign body
(B) Attempt battery removal by the Foley balloon catheter technique
(C) Immediate GI consultation for endoscopic removal
(D) Immediate surgical consultation
(E) Discharge to home with parental observation and weekly radiographs

The answer is E. Button batteries lodged in the esophagus require emergencyremoval to avoid esophageal burns and perforation. If the button battery has passed the esophagus and the patient is asymptomatic, home observation with serial x-rays toensure passage through the pylorus is the appropriate course of action. Most button batteriesthat have passed the esophagus will transit through the entire body within 24 to 48 h without difficulty. If the battery is of large diameter and the patient is younger than 6
years, the battery is less likely to pass, and endoscopic retrieval is the preferred treatment.

answer is E. Because the pancreas adheres to the posterior duodenum, ruptured posterior duodenal ulcers generally penetrate into the pancreas rather than perforate into the free peritoneum. Anterior ulcers are more likely to perforate into the peritoneal cavity. A Mallory-Weiss tear of the esophageal wall usually presents with
symptoms similar to reflux esophagitis and causes moderate, self-limited bleeding. Patients with Boerhaave’s syndrome rapidly deteriorate to a state of shock and septicemia
due to a malignant mediastinitis.

23- A 55 y/o male without significant medical history presents with LLQ pain and constipation. V/S: T= 100.5°F, PR= 85, BP=150/80, RR=12. P/E is unremarkable except for mild LLQ tenderness without guarding and rebound. Rectal examination shows heme-negative stool and no tenderness.Lab results are within normal limits except for WBC=13,000 with a left shift. Which of the following would be the MOST appropriate management for this patient?
(A) Prompt surgical evaluation in the ED
(B) Emergent upper GI series
(C) Emergent barium enema
(D) Discharge to home with bowel rest and oral antibiotics
(E) Discharge home with repeat abdominal examination in 12 h or sooner if worse

The answer is D. The patient described in the scenario most likely has diverticulitis. Patients with localized pain and no signs and symptoms of peritonitis or systemic infection do not require hospitalization. Outpatient management consists of bowel rest, broad-spectrum oral antibiotic therapy, and close follow-up.

24- Which of the following etiologic agents is the MOST common cause of infection in liver transplant patients?
(A) Candida
(B) Cytomegalovirus
(C) Herpes simplex virus
(D) P. carinii
(E) L. monocytogenes

The answer is B. Complications of infections in liver transplant patients account for nearly 90 percent of deaths. The most common infectious agent after transplantation is Cytomegalovirus (CMV. Reported occurrence ranges from 23 to 85 percent of all liver transplant patients. Fortunately, CMV is rarely fatal.

The answer is B. GI bleeding is a common problem seen in the ED and is potentially life threatening. For patients with significant active bleeding, emergency endoscopy is the treatment of choice. Esophageal varices can be treated endoscopically with either band ligation or sclerotherapy, resulting in control of acute bleeding in up to 90 percent of patients. Hemostasis can be achieved with nonvariceal sources of bleeding as well. Drug therapy with both octreotide and somatostatin reduces bleeding from both varices and PUD and is a useful adjunct to endoscopy. Vasopressin therapy has largely been discontinued due to a high rate of adverse effects including hypertension, arrhythmias, myocardial ischemia, and decreased cardiac output. Balloon tamponade can be used as a temporizing measure to control bleeding by placing direct pressure on the gastric and esophageal mucosa. However, it is frequently associated with complications, including mucosal ulceration, esophageal or gastric rupture, asphyxiation from dislodged balloons, and aspiration pneumonia. Although it is appropriate to make a surgeon aware of a critical patient, emergency surgical intervention is indicated only in those patients who fail endoscopic hemostasis and medical therapy.

*** 36 y/o woman with meno/metrorrhagia, inlarged uterus, which of the ffg would tell the severity of this condition?
a- CBC
b- Hysteroscopy
c- US
d- Pelvic exam

It’s US, when severity of the condn is asked, it need not necessarily mean
bleeding (submucosal and intramural) it could be pressure sym also(subserosal), hence US. to add, since 36 yr most common is fibroids since adenomyosis in the premenopausal, tho' both can have meno metrorrhagia.

*** Which of the ffg is a contraindication for vaginal delivery after previous c/s ?
a- Low segment transverse uterine incision
b- breech
c- clinically adequate pelvis
d- placenta previa
a. repeat cs possible, unless longitudinal incision, not done nowadays.
b. vaginal can be done.
c. prerequisit for vaginal.
d. regardless of previous delivery, since the incision would be on the low implanted placenta- torrential bleeding unless the (lower placental edge is more than 2cm from the internal os and it the first
delivery without previous CS
answer is d.

19 y/o with a small lump in her Lt./ breast is very concerned that it’s malignant cancer, work up & Bx shows it’s benign, but she is still extremely worried inspite of reassurance by her physician. Which of the ffg is the best Tx in this case?
A- a careful explanation of benign nature of the complaint
B- Use of benzodiazepine
C- Skillful physician reassurance
D- Use of placebo medication
E- Psychotherapy to explore her current life circumstances

Answer is E. case of hypochondriasis which is usually becomes evident during psychological stress.

Answer is D. Visceral larva migrans is caused by Toxocara larva. It’s most common in children 1-4 y/o especially who have close contacts with digs & cats. Sandboxea are common places for both pets & children. Sx are: fever, hepatosplenomegaly, wheezing, pulmonaer dis. & eosinophilia

Answer is A. Maintanace therapy after response to antidepressants should be continued for 6 months after initial response.

14 y/o girl presents with trouble concentrating at school just three months after witnessing her best friend being shot to death by another classmate. Ever since that "awful day" she has been very "sad" and withdrawn, often sitting on her bed, staring at the wall "for hours." She has frequent crying spells and refuses to play with friends or participate in her normal after-school activities. Her appetite has "dwindled down to nothing" and she feels very guilty that she survived the shooting. On further questioning, she reluctantly admits that she has constant thoughts of "joining her friend." She did not receive any counseling after the incident.
*** What’s the most likely Dx?
A. adjustment disorder
B. brief psychotic disorder
C. dysthymic disorder
D. major depressive disorder
E. normal grief
F. PTSD

*** What’s the most important q to ask at this time?
A. "Are you hearing voices?"
B. "Do you have any friends that you feel comfortable talking to at school?"
C. "Do you wear a helmet when you ride your bicycle?"
D. "Can you describe your typical weekly alcohol intake?"
E. "Have you thought of the means by which you can 'join your friend'?"

1- The correct answer is D. This patient most likely has major depressive disorder. To meet the criteria for this disorder a patient must exhibit a 2-week history of a distinct change in mood or a loss of interest or pleasure, along with at least 4 of the following: a decreased appetite and weight loss, difficulty sleeping, psychomotor retardation or agitation, fatigue, feelings of worthlessness or guilt, an inability to concentrate, and suicidal ideation. The symptoms must cause functional impairment. ( Kaplan, step 3 samples )

2- The correct answer is E. Since she has already told you that she has suicidal ideation ("joining her friend"), it is very important to ask if she has "thought of the means by which" she can "join her friend" or has made any preparatory actions.

A 64 y/o married man has been diagnosed to be HIV positive. He comes in to the office to discuss the results and begs you not to tell his wife, who is also your patient. He says that hearing what he has been in involved in "will kill her." You remind him that HIV may also "kill her." The most appropriate first step is to:

A. contact his wife anonymously and tell her that she has been exposed to HIV
B. contact the appropriate government health agency and report your findings
C. promise him that as his doctor you will respect his privacy and maintain confidentiality
D. promise him that you will keep the results confidential if he agrees to use condoms with his wife
E. try to persuade him to voluntarily discuss the issue with his wife

The correct answer is E. Physicians must violate confidentiality and warn third persons about the danger of HIV infection if the patient is unwilling to inform the person himself. Before informing third parties, the physician should try to do everything possible to persuade the patient to voluntarily discuss the issue with their partner. If the physician believes that an individual may really be saved from a deadly infection, confidentiality should be violated.

A 4 y/o boy presents with fever, irritability, and erythema of the hands and feet for the past week. His mother has been giving him aspirin to reduce his temperature. P/E on admission showed a T=39.7 C (103.4 F), bilateral conjunctival injection, an enlarged right-sided cervical lymph node (1.8-cm), fissured lips, a red tongue with red papillae, pharyngeal hyperemia, erythematous and edematous palms and soles, and a confluent, blanching erythematous rash on the trunk. IV fluids were started, the aspirin therapy was continued. Laboratory studies show ESR= 28mm/h Plt= 490,000/mm3. The patient is extremely uncomfortable and now shows desquamation of the fingers and toes. The most appropriate therapy at this time is:

The correct answer is C. This patient most likely has Kawasaki disease, which is treated with aspirin and intravenous gammaglobulin. The disease is characterized by a high fever for longer than 5 days, bilateral conjunctival injection, fissured lips, a "strawberry tongue", mucosal change in the oral pharynx, erythematous and edematous palms and soles with desquamation, a polymorphous rash, cervical lymphadenopathy, an elevated erythrocyte sedimentation rate, and thrombocytosis. The most important complication is coronary artery aneurysms, which may be prevented by early treatment with aspirin and intravenous gammaglobulin. An echocardiogram is necessary to evaluate cardiac involvement.

47 y/o woman with a Hx of similar attacks of epigastric abdominal pain in the past was admitted to the hospital with a Dx of gallstone pancreatitis. She was NPO and IV fluid started. On the evening of admission day, the patient is noted to have T=103.4 F. Her BP & HR are within normal range. Her abdomen is diffusely tender to palpation with guarding. What’s the most appropriate management at this time?

The correct answer is B. The most appropriate management at this time is to draw blood cultures and initiate ampicillin, gentamicin, and metronidazole therapy. Intravenous antibiotics are only indicated if there is evidence of pancreatic necrosis or if the patient develops a fever after the diagnosis of pancreatitis is made. There is a substantial amount of clinical literature validating this approach to treating pancreatitis. The appropriate sequence of events is to draw blood cultures prior to initiating therapy in order to maximize chances of detecting an organism.

A 24 hour old male infant is noted to have some peculiar jerking movements of the right foot and arm. His axillary temperature an hour before was 36.2"C. The physical examination reveals no unusual findings except that he appears small and premature. His birth weight was 2,550 g. The mother's and infant' s history show that he was the second of twins born after 37 weeks' gestation, presented in transverse position and his heart rate had dropped to 80 per minute 10 minutes prior to birth, with documented fetal hypoxia. He had an Apgar score of 3 at 1 minute and 7 at 5 minutes. The mother had nausea and vomiting during pregnancy for which she was given vitamin B6. She had mild preeclampsia at delivery.
*** Which is the most likely diagnosis?
a) Brain tumor
b) Hypoxemia in utero and possibly during delivery
c) Cerebral trauma during delivery
d) Vitamin B6 dependency
e) None of the above
*** In the diagnostic work-up, you may obtain the following tests or procedures, EXCEPT:
a) CT scan of the head
b) Lumbar puncture for examination and culture of spinal fluid
c) Electroencephalography
d) Serology for toxoplasmosis
e) Blood levels of sugar and calcium
B & D
Hypoxemia is the leading cause of seizures considering the history of drop in fetal heart rate and low Apgar score at 1 minute. Hypoglycemia, hypocalcemia, vitamin B6 dependency, and meningitis are possible causes of seizures but unlikely and should be ruled out. Some cerebral anomaly is possible. Incidence of congenital malformations is higher in twins than , in singletons, and central nervous system malformations lead all others in frequency. Brain tumors at this age are rare and usually present with recurrent vomiting and not with seizures.

An infant who was healthy at birth is brought to your office for her first office visit at the age of 6 weeks. You notice that the infant is jaundiced and that there is bilirubin staining of the wet diaper. Which one of the following diagnoses is most consistent with these findings?
a. Physiologic jaundice of the newborn
b. Hemolysis secondary to Rh incompatibility
c. Crigler-Najjar syndrome
d. Gilbert's syndrome
e. Biliary atresia
Answer is e- biliary atresia. bilirubbin in urine a clue of direct hyperbilirubinemia

Which of the following statements best describes the current condition?
a-He is in the incubation period, is highly infectious, is likely to develop acute hepatitis B.
b-He is in the incubation period, is minimally infetious, and is likely to develop acute hepatitis B.
c-He is a chronic carrier of hepatitis B and is highly infectious.
d-He was infected previously with hepatitis B. has recovered and is immune to hepatitis B.

Answer is a.

A 35 y/o woman requests a routine health assessment. She has no specific medical complaints or past medical hstory. Her father developed colon cancer at age 54 but is still living. His brother died of colon cancer at aae 41. Their father (the patient's grandfather) died in his sixties of colon cancer. His sister died of gastric cancer. The patent's sister was recently diagnosed with endometrial cancer at age 43.
The patient has a good appetite and has no nausea, vomiting, or weight loss. She has had no change in her bowel habits or hematochezia, and her menstrual periods are normal. Physical examination is normal. Digital rectal examination is negative for fecal occult blood. A screening complete blood count and biochemical profile are normal.
Which of the following actions is most appropriate?
a. Perform annual occult blood tests of three stool specimens. Initiate screening with flexible sigmoidoscopy at age 50.
b. Perform colonoscopy at least every 2 years.
c. Barium enema now; if normal no further evaluation.
d. Perform colonoscopy now; if no polyps are seen, no further investigation is necessary.
e. Perform fecal occult blood testing and flexible sigmoidoscopy now. If no polyps are seen now, the patient should be followed routinely with fecal occult blood testing and flexible sigmoidoscopy beginning at age 50.
Answer is b.

A 20 y/o woman is evaluated for fever of nine weeks’ duration. During this time she has had daily temperature elevations to 40.0 C (104.0 F). The only other symptoms have been malaise and occasional aches in the hands and knees; on one occasion she noted a transient pink rash on the abdomen. A one-week course of ampicillin had little effect.
T=38.9 C (102.0 F); PR=108 per minute, and rhythm is regular. A grade 1/6 systolic ejection murmur is heard best at the LSB. The spleen is palpable 3 cm below the left costal margin on deep inspiration. Electrocardiogram and chest radiograph are normal. Laboratory studies:
Hct 35%
Hgb 11.5 g/dL
WBC 12,800/cu mm; 81%neutrophils,
4% monocytes, 14 lymphocytes,
1% eosinophils
ASO 250 Todd units {<200}
RF Negative
ANA Negative
Blood cultures Pending
Which of the following is the most likely diagnosis?
(A) Enteric fever
(B) Bacterial endocarditis
(C) Lyme disease
(D) Hodgkin's disease
(E) Adult-onset Still's disease
Answer is e.

A healthy 71 y/o man describes visual loss in his right eye. Flashes of light and a curtain-like loss of lateral vision began when he awoke eight hours ago. These symptoms have persisted. Which of the following is the most likely explanation?
(A) Retinal vein occlusion
(B) Retinal detachment
(C) Atheroembolic occlusion of a lateral branch of the right retinal artery
(D) Ocular migraine
(E) Occipital lobe seizure
Answer is B.

What is the marker for CREST syn. ?

A. anti-scl-70
B. anti centromere
C. anti ds-DNA
D. SS-A (Ro)

The marker for CREST is anti centromere. They both have C in it.

anti-scl-70 is for scleroderma diffuse type. They both have scl in it.

the answer is A. Rapidly progressive glomerulonephritis is characteristic of rapidly losing at least 50% of its glomeruli in as short period of time--usually days to 3 month max. Extensive fibrinoid necrosis is found on biopsy.

Answer: depending on senario if pt is unstable proceed to Pericardiocentesis, If stable echo first.

A patient has end stage pancreatic cancer and as her primary care pysician, she asks you how long she could survive. What you should tell her.
a. 5 year rate is 30%
b. 5 year rate is 20%
c. " 15%
d. " < 5%

Answer: D- The overall 5-year survival rate for this disease is less than 5%.

A 24-year-old white primigravida has developed several 1- to 2-mm erythematous papules on her abdomen in the third trimester. They are pruritic and tend to appear in her striae. Liver function tests and a CBC are normal.

The findings in this patient are most consistent with PUPP. This condition is usually benign, is not associated with increased fetal morbidity, and resolves after delivery, and there is usually no recurrence in subsequent pregnancies. Herpes gestationis, impetigo herpetiformis, and Spangler's papular dermatitis have different presentations and may be associated with increased fetal morbidity. Pruritus gravidarum is characterized by pruritus without skin lesions.

a. weekly speculum examinations under aseptic conditions beginning in her third trimester to assess the risk of bleeding
b. an MRI scan, with a repeat scan later in the pregnancy if indicated
c. repeat ultrasonography in her third trimester
d. cesarean delivery at 28 weeks gestation if her L/S ratio is favorable
e. reassurance that ultrasound diagnosis of placenta previa without evidence of bleeding is no cause for concern and can be disregarded

The ans is c

The incidence of placenta previa ranges from 6% to 45% in the second trimester, but more than 95% of these resolve by the third trimester. However, it remains a cause for concern and should be watched, not ignored, even if there is no bleeding. This patient should have repeat ultrasonography in her third trimester. An MRI is very helpful but need not be used except in a difficult diagnostic situation. Weekly speculum examinations would create a risk of hemorrhage. Delivery at 28 weeks would not be appropriate in a patient with no symptoms and without confirmation of the persistence of placenta previa.

Which one of the following is an absolute contraindication to tocolytic treatment for preterm labor?
a. Urinary tract infection
b. Documented gestation less than 28 weeks
c. Chorioamnionitis
d. Uncontrolled diabetes mellitus
e. Any vaginal bleeding due to mild abruptio placentae

The ans is c
Before tocolytic treatment is instituted, absolute contraindications to tocolysis must be ruled out. These include chorioamnionitis, severe abruptio placentae, severe bleeding from any cause, severe pregnancy-induced hypertension, fetal death, fetal anomaly incompatible with life, and severe fetal growth retardation. Chorioamnionitis may precipitate preterm labor and is an absolute contraindication to tocolysis. It may be present in a febrile pregnant patient even with intact membranes. In this case amniocentesis may be required to rule out infection. There are also a number of relative contraindications. These include uncontrolled diabetes, hyperthyroidism, maternal cardiac disease, mild chronic hypertension, mild abruptio placentae, stable placenta previa, fetal distress, fetal anomaly, mild fetal growth retardation, and cervical dilatation greater than 5 cm. In patients with relative contraindications to tocolysis the risk of complications from prematurity must be weighed against the risk of tocolysis. Not all vaginal bleeding is due to a serious obstetric condition. Cervical effacement or dilatation may be the cause. Even if the source of bleeding is determined to be a placental abruption, if the bleeding is minor, the abruption is mild, and the fetus is not in distress, tocolysis is not absolutely contraindicated.
While diabetes mellitus may be adversely affected by beta-adrenergic tocolytic agents, it is not an absolute contraindication to tocolysis. Close glycemic monitoring is, of course, mandatory. Even a few weeks of effective tocolysis may significantly alter the perinatal outcome of gestations between 25 and 27 weeks. Gestational age less than 28 weeks is therefore not a contraindication to tocolysis. While a urinary tract infection may precipitate preterm labor, tocolysis is not contraindicated. The infection, of course, should be treated.

Which one of the following statements is most accurate concerning juvenile rheumatoid arthritis?
a. Fever is a rare systemic manifestation
b. Ten years after the onset of disease, most patients have excellent functional status
c. Most patients have a permanent deformity of at least 1 extremity
d. The disease is characterized by lifelong recurrences
e. Most patients require corticosteroid treatment

answer is b.
At least 50% of patients followed for up to 15 years have complete remission of juvenile rheumatoid arthritis, and 70% regain normal function. A few patients are left with crippling joint deformities, but 75% have no significant residual deformity. Systemic-onset disease is accompanied by high fever, rheumatoid rash, polyarthritis, and other systemic manifestations

A 5-year-old African-American male fell off his bicycle and hit the back of his head on a hard surface. There was no loss of consciousness. No other injury was noted. He was obviously agitated and restless, and his only complaint was a loss of vision. When you see him, his examination is unremarkable except for moderate swelling over the occipitoparietal area of the scalp. His skin is intact, and no gross neurologic deficit is noted except for the visual loss. A CT scan is negative. An EEG shows only slight slowing of activity.
Which one of the following statements is true regarding this patient?

a. The child's vision will probably return within 24 hours
b. The child should be hospitalized for 72 hours for further observation
c. It will be months before the child's vision returns
d. The loss of vision is probably caused by damage to the optic nerve

Ans is a
Transient cortical blindness following mild head trauma is usually associated with a benign outcome. The special features are mild head trauma, no loss of consciousness, onset of blindness occurring within hours of the trauma, duration of blindness less than 24 hours, absence of skull fracture or visible injury on CT scan, and no other neurologic deficits. The EEG shows initial slowing with normalization on follow-up.

which of the following medication is known to exacerbate psoriaisis?
a)prednisone
B NSAID
c hydroxychloroquine
d methotrexate

answer is c.

1- A 20 y/o man who moved to the US from Cambodia 2 years ago presents to the ER with the sudden onset of left hemiparesis. His wife, who emigrated with him, reports that he has not felt well for at least a month and has had a weight loss of about 9 kg (20 lb). On P/E, T=38 °C (100.4 °F) and BP=116/52 mm Hg. He is somewhat cachectic and hemiparetic. The cardiac examination shows a murmur. The physical examination is otherwise normal.Which of the following tests is most likely to give the diagnosis?
(A) Blood cultures
(B) Lumbar puncture
(C) Radiography of the chest
(D) Complete blood count, differential, platelet count, and erythrocyte sedimentation rate
(E) Biopsy of inguinal lymph node
(F) head CT scan
Answer is A.The appearance of focal neurologic signs in a young person from Cambodia raises a wide differential diagnosis. Atherosclerotic cerebrovascular disease is uncommon in the 20-year-old age group. Among other diagnostic considerations are an embolic event from a cardiac source, such as a valvular vegetation associated with endocarditis or an atrial myxoma; vasculitis; tuberculomatous or bacterial brain abscess; brain tumor; aneurysm or arteriovenous malformation; and coagulation disorder such as thrombotic thrombocytopenic purpura or hyperviscosity syndrome caused by multiple myeloma.
Neurologic complications occur in 25% to 40% of patients with infective endocarditis. About 15% develop cerebral emboli with associated neurologic symptoms. The easily associated triad of new focal neurologic deficits, fever, and changing heart murmur occurs in only 33% of patients, so infective endocarditis must be considered in any patient with sudden focal neurologic deficits who has no conventional risk factors, such as atherosclerosis.

2- A 35 y/o woman presents with a 1.5-cm Lt breast mass which is nodular with indistinct borders. Her mother and maternal aunt both had breast cancer in their forties.
How would you evaluate this woman's condition?
(A) Observe through a menstrual cycle
(B) Diagnostic mammogram
(C) Breast ultrasound
(D) Office needle aspiration
This woman has a significant risk for breast cancer. The suspicion of cancer is high because of the characteristics of the mass and the family history of early-age breast cancer. The first approach would be a diagnostic mammogram to further define the lesion and, equally important, to look for suspicious lesions in the opposite breast. Even if the mammogram is negative, referral to a surgeon for biopsy would be the next step.

3- A 22-year-old female primagravida is seen in prenatal clinic 5 months after her last menstrual period. Her pregnancy has been uneventful, and she has gained weight progressively over the last 2 months. Three months ago, her blood pressure was 120/80 mm Hg, and there was 2+ protein on dipstick urinalysis. Today she has a blood pressure of 150/95 mm Hg and marked bilateral lower extremity edema.
Laboratory studies:
Hematocrit 29.7%
Leukocyte count 4200/L
Platelet count 209,000/L
Blood urea nitrogen 15 mg/dL
Serum creatinine 1.1 mg/dL
Serum uric acid 6.0 mg/dL
Urinalysis:
Protein 4+
Microscopic Hematuria, rare erythrocyte casts, rare broad casts, few leukocytes
24-hour urine protein excretion 12.5 g
Creatinine clearance 80 mL/min
This clinical presentation is most consistent with:
(A) Preeclampsia
(B) Underlying renal disease present before conception
(C) Hypertensive nephrosclerosis
(D) Pyelonephritis
Answer is B. In this 22-year-old pregnant woman, it is critical to determine whether previously existing underlying renal disease is present because of the overlap with signs of preeclampsia and the differing prognoses of the two conditions. Preeclampsia is a complication that presents after 20 weeks of gestation, which suggests the abnormal proteinuria in this patient is associated with another disease. The finding of 2+ protein on dipstick urinalysis is not specific, but the hematuria and erythrocyte casts suggest underlying glomerulonephritis rather than preeclampsia.

4- A 50-year-old man who has had diabetes mellitus for 12 years is concerned about becoming dependent on dialysis. His disease has been inadequately controlled (hemoglobin A1C range 8.7% to 11.8%). His urinalysis is strongly positive for protein, and his serum creatinine concentration has increased from 1.2 to 1.9 mg/dL in the past 8 months. His blood pressure has been 150/90 mm Hg and on occasion as high as 210/120 mm Hg. Which treatment is most important to reduce the process of this patient's kidney disease?
A. Insulin
B. Antihypertensive agent
C. HMG-CoA reductase inhibitor ("statin")
D. Protein-restricted diet
E. Aspirin
Answer is B. This patient has already started on the path to progressive diabetic nephropathy. Although all of the preventive measures still warrant attention, blood pressure control at this stage is most important. From the onset, good glycemic control (hemoglobin A1C 7% to 7.5%), a protein-regulated diet to reduce intraglomerular pressure as well as antihypertensive therapy with an ACE-inhibitor should be considered.Antihypertensive therapy attenuates the decline in renal function in patients with all forms of diabetes.

5- A 26-year-old patient is presented with amenorrhea of 2.5-month duration. Lab analysis indicates increased levels of thyroid and cortisol binding proteins. There is an elevated total cortisol and ACTH. Free cortisol level is within normal range. These findings are most likely suggestive of which of the following conditions?

Two weeks following a viral illness, a teenage boy breaks out in an evolving rash that is remarkable for target lesions. What is the primary treatment?
a. Epinephrine
b. Glucagon
c. Corticosteroids
d. Antihistamines
e. Symptomatic or supportive therapy depending on severity.
Answer is e. it’s erythema multiform

A 60 y/o Japanese man visiting US with excellent health until 6 months ago, when he first noted mild upper abdominal fullness after meals. On P/E hyperpigmented, heaped-up velvety lesions in the neck, axillae, and groin is noted. Which of the following conditions is associated with the skin findings?

a- Non-Hodgkin's lymphoma

b- Anorexia nervosa

c- Acute leukemia

d- Adenocarcinoma of the stomach

e- Addison's disease

Answer is d, skin lesion is acanthosis nigricans.

Which of the following should be done annually after age 40 in the asymptomatic, average- risk man in order to promote the early detection of cancer?

a- Colonoscopy

b- Sigmoidoscopy

c- Digital rectal examination with palpation of the prostate

d- Digital rectal examination with palpation of the prostate and stool guaiac

During a routine checkup, a 65 y/o man is found to have a level of serum Alk Ph. three times the upper limit of normal. Serum Ca and ph. concentrations and LFT results are normal. He is asymptomatic. The most likely diagnosis is

a- metastatic bone disease

b- primary hyperparathyroidism

c- occult plasmacytoma

d- Paget's disease of bone

e- osteomalacia

answer is d.

Which of the following is NOT a predisposing factor for the development of a hernia?
a- Ascites
b- Obesity
c- Cystic fibrosis
d- Chronic obstructive pulmonary disease
e- Peritoneal dialysis

A 5-month-old infant has had several episodes of wheezing, not clearly related to colds. The pregnancy and delivery were normal; the infant received phototherapy for 1 day for
hyperbilirubinemia. He had an episode of otitis media 1 month ago. There is no chronic runny nose or strong family history of asthma. He spits up small amounts of formula several times a day, but otherwise appears well. His growth curve is normal. An examination is unremarkable except for mild wheezing. Which one of the following is the most likely diagnosis?
A) Benign reactive airway disease of infancy
B) Cystic fibrosis
C) Unresolved respiratory syncytial virus infection
D) Early asthma
E) Gastroesophageal reflux

Answer is E, gastroesophageal reflux is a common cause of wheezing in infants. At 5 months of age, most infants no longer spit up several times a day, and this is a major clue that the wheezing may be from the reflux. Also, there is no family history of asthma and the wheezing is not related to infections. Cystic fibrosis is more likely to present with recurrent infections and failure to thrive than with intermittent wheezing.

*** ECG findings of pulmonary edema include all of the following except:
a- deep S1
b- depressed ST in lead I & II
c- prominent Q1 & inversion of T3
d- left axis deviation
e- clockwise rotation in the precordial leads

answer is d. association of thymoma and myasthenia gravis. 5-10% of Px with thymoma have low serum gamma globulins.

*** 76 y/o male with 80 pack/y smoking Hx, was diagnosed with lung cancer 4 m ago, he’s brought to hospital in state of coma, his serum ca= 16 mg/dl, which of the ffg, would be the most useful to reduce ca rapidly:
a- acetazolamide
b- furesmide
c- hydrochlorothiazide
d- manitol
e- spironolactone

answer is b- furesmide which increase urinary excretion of ca.

*** 50 y/o man with Hx of smoking & cough for the past 2 months, is found to have a solitary pulmonary nodule with no mediastinal dis on CXR. He’s expected to have best prognosis if he has which type of ffg tumors?
a- small cell carcinoma
b- poorly diff. Adenocarcinoma
c- metastatic carcinoma
d- well diff. SCC
e- well diff. Adenocarcinoma

answer is e- well diff adenocarcinoma

*** 27 y/o woman presents with sudden pain & decrease in hearing in Rt. ear while picking it with matchstick. On P/E, a traumatic rypture of Rt. tympanic membrane & some blood clot is seen. What’s the best advice or procedure?
a- advice her to use earplug while shampooing & showering
b- advice her to clean the ear canal with Q-tips
c- remove the blood clot
d- antibiotic eardrops
e- oral + eardrop antibiotics

*** Which of the following lab values would be most consistent with a woman who has a Hx of lung cancer and has been on chemotherapy for several weeks.The patient now presents with acute anemia.
a. reticulocyte count of 60 x 109
b. plasma Hgb of 7.2 g/dl
c. Hct of 34%
d. MCV of 70 fL
e. RBC of 5.9 million/mm3

answer is a.

*** A healthy 12-month-old boy has a brother with adenosine deaminase deficiency. Which of the following vaccines should you NOT administer to the infant?
(A) Diphtheria-tetanus-pertussis (DTP)
(B) H. influenzae (HiB)
(C) Hepatitis B (Hep B)
(D) Oral polio vaccine
(E) Measles-mumps-rubella (MMR)
answer is D- The main problem in this scenario is administering a live, attenuated vaccine that may be followed by transmission to the immunocompromised sibling and cause severe, possibly fatal, disease. Of the attenuated vaccines, the oral polio vaccine is the most dangerous because the virus is shed in the feces, while attenuated vaccines administered by inoculation (such as measles-mumps-rubella), which are not shed by the recipient, are considerably less likely to be transmitted from person to person. The other three vaccines are not live vaccines and have no special risk in an immunocompromised individual

*** A 30-year-old man sustains brain damage as the result of an automobile accident. Neurologic examination reveals incomplete retrograde amnesia and severe anterograde amnesia as well as inappropriate social behavior, including hyperphagia, hypersexuality and general disinhibition. The brain injury would most likely involve the:
(A) frontal lobes, lateral convexity.
(B) frontal lobes, medial surface.
(C) temporal lobes, lateral convexity.
(D) temporal lobes, medial surface.
(E) thalami.
Answer is D- Bilateral damage of the medial temporal gyri, including the amygdalae, may cause severe memory loss (hippocampal formations). Such damage to the amygdalae may lead to inappropriate social behavior (e.g., hyperphagia, hypersexuality, general disinhibition). Bilateral destruction of the amygdalae results in the Klüver-Busy syndrome.

*** A 24 y/o college student, G1P1 presents for her annual pelvic examination and Pap smear, and renewal of her ocp. Hx & P/E are unremarkable. Her Pap smear is subsequently reported as high-grade squamous intraepithelial lesions (HGSIL). The most appropriate next step in this patient's management is
(A) Repeat Pap smear in one year.
(B) Repeat Pap smear now.
(C) Colposcopy with ECC and directed biopsy.
(D) Excisional biopsy.
(E) Cervical conization.

Answer is C. HGSIL on screening examination requires histologic diagnosis so that appropriate treatment can be selected. Repeat Pap smear is another screening test and is thus inappropriate. Conization for diagnostic purposes is needed only if colposcopy and biopsy prove inadequate.

*** A 63 y/o man with no significant past medical history is admitted with an acute abdomen secondary to gastric perforation. If a definitive ulcer procedure is performed on this patient, which of the following procedures is associated with the lowest ulcer recurrence rate?
(A) Truncal vagotomy
(B) Truncal vagotomy and pyloroplasty
(C) Vagotomy and antrectomy
(D) Parietal cell vagotomy
(E) Gastric bypass
answer is c. Among the choices provided, vagotomy with a simultaneous antrectomy has the lowest ulcer recurrence rate. However, this procedure is associated with a higher morbidity secondary to anastomotic complications (e.g., leak or stricture) or problems associated with denervation of the proximal stomach and distal bowel. Complications include postvagotomy diarrhea, dumping syndrome, delayed gastric emptying and alkaline reflux gastritis.

*** A 16 y/o boy presents to his physician with a history suggestive of systemic lupus erythematosus. The patient has a rash, arthralgia and mild proteinuria. Serologic evaluation detects no antibodies of diagnostic value. Which one of the following diseases is most likely to be diagnosed in this patient?
(A) Rheumatoid arthritis
(B) Common variable hypogam-maglobulinemia
(C) C2 deficiency
(D) Sjögren's syndrome
(E) Wegener's granulomatosis

answer is c. A deficiency in complement component C2 may manifest itself as a disorder similar to systemic lupus erythematosus, possibly because of a failure of complement-dependent mechanisms to eliminate immune complexes. Most patients with rheumatoid arthritis have several antibodies (most notably the anti-IgG antibody known as rheumatoid factor). Similarly, Sjögren's patients are diagnosed by detection of antibodies to exocrine gland duct epithelium. Patients with Wegener's granulomatosis have antineutrophil cytoplasmic autoantibodies. Common variable hypogammaglobulinemia will evidence itself by the occurrence of repeated bacterial infections.

Answer is a. Px has infective endocarditis due to staph, aureus involving aortic valve.the nodules are osler’s nodes and nailbed finding is splinter hemorrhage and both are example of immunocomplex vasculitis.

4- on a routine examination of a 5 y/o female a heart murmur is heard. It’s medium pitched, systolic ejection murmur, with musical quality. Which of the ffg is the characteristic of this murmur:
a- it’s best heard along the lower Lt. & midsternal border
b- it’s common in infancy
c- it’s best heard while Px is lying down on the Lt.
d- it’s less intense with fever or excitement

answer is A. an innocent murmur, which is best heard in supine position. It occurs only in systole ( never in diastole ), uaually grade I or II, and heard on LSB in children between ages 3-7 ( rarely in infancy ).

** 35 y/o woman had an attack of billiary colic. which analgesic is contraindicated and why?
morphine increase intrabilliary pressure which worsens the pain.

1- A 70-year-old African-American male who has been hospitalized for 2½ weeks for congestive heart failure develops severe, persistent diarrhea. For the past 3 days he has had abdominal cramps and profuse semi-formed stools without mucus or blood. The patient’s current medications include captopril (Capoten), digoxin, furosemide (Lasix),
subcutaneous heparin, spironolactone (Aldactone), and loperamide (Imodium). He has coronary artery disease, but has been relatively pain free since undergoing coronary artery bypass surgery 4 years ago. An appendectomy and cholecystectomy were performed in the past, and the patient has since been free of gastrointestinal disease. On physical examination his blood pressure is 100/80 mm Hg, pulse 100 beats/min and regular, and temperature 37.0° C (98.6° F). He has mild jugular venous distention and crackles at both lung bases. Examination of his heart is unremarkable, although there is 1+ dependent edema. His abdomen is diffusely tender without masses or organomegaly. Rectal examination is normal. The results of routine laboratory tests, including a CBC, chemistry profile, EKG, and urinalysis, are all normal. The stool examination shows numerous white blood cells. Of the following, the most likely diagnosis is
A) viral gastroenteritis
B) Clostridium difficile colitis
C) ulcerative colitis
D) gluten-sensitive enteropathy (celiac sprue)
E) digoxin toxicity

This patient most likely has Clostridium difficile colitis, suggested by semiformed rather than watery stool, fecal leukocytes (not seen in viral gastroenteritis or sprue), and a hospital stay greater than 2 weeks. While this disease has traditionally been associated with antibiotic use, it is posing an increasing threat to patients in hospitals and chronic-care facilities who have not been given antibiotics. The primary sources for infection
in such cases have been toilets, bedpans, floors, and the hands of hospital personnel. Prompt recognition and treatment is essential to prevent patient relapse and to minimize intramural epidemics. The diarrhea of ulcerative colitis usually contains blood and occurs intermittently over a protracted course. Digoxin toxicity is likely to be accompanied by electrocardiographic and laboratory abnormalities, particularly hyper- or hypokalemia.

2- A 79-year-old man is admitted to the medical ward 3 days status post subdural hematoma drainage, C3 cervical spine fracture, and fixation of multiple extremity fractures sustained in a motor vehicle accident. The patient is now awake and oriented to person, place, and time, but is a lower cervical spine incomplete quadriplegic. Physical examination reveals some minimal sensation in the legs, but no ability to move the extremities. There is a Foley catheter in place that is draining yellow colored urine. Doppler ultrasonography demonstrates a thrombus in the left popliteal vein. The most important next step in the management of this patient is
A. daily Doppler ultrasonography of the lower extremities
B. inferior vena cava filter placement
C. subcutaneous heparin
D. tissue plasminogen activator thrombolysis
E. warfarin
F. weekly ventilation/perfusion scans for a pulmonary embolus

The correct answer is B. This patient has documented deep venous thrombosis (DVT) on ultrasonography and has had recent intracranial surgery. Intracranial surgery is an absolute contraindication to anticoagulation. Because the patient has a documented DVT, an inferior vena cava filter is necessary to prevent potentially fatal pulmonary emboli.

Daily ultrasonography of the lower extremities (choice A) is a way to follow the extent of the documented thrombus in the left popliteal vein. It is not sufficient to simply follow the extent of the clot, however. The known DVT puts him at a risk for a pulmonary embolus, and therefore he needs an inferior vena cava filter.

Anticoagulation with subcutaneous heparin (choice C) is absolutely contraindicated as the patient has had recent neurosurgery.

Thrombolysis (choice D) will treat the current thrombus in the left popliteal vein, but it will not prevent further thromboses from occurring. Thrombolysis with tissue plasminogen activator is also contraindicated so soon after intracranial surgery.

Anticoagulation with warfarin (choice E) is absolutely contraindicated as the patient has had recent neurosurgery.

A screening study for pulmonary emboli (choice F) is inadequate for this high-risk patient. Although both ventilation/perfusion scanning and CT pulmonary angiography are effective studies to diagnosis a pulmonary embolus, this patient needs definitive treatment to prevent a pulmonary embolus.

3- A 23-year-old college student comes to the clinic because of odynophagia with solids and liquids and dysphagia that is most severe when eating solid foods. The patient had a past medical history of Shigella colitis last year while she was a Peace Corps volunteer in Peru. She takes oral contraceptives and smokes 1 pack of cigarettes daily. She does not drink alcohol. Vital signs are: temperature 37.8 C (100 F), blood pressure 100/70 mm Hg, pulse 79/min, and respirations 8/min. Physical examination is normal. Electrocardiogram reveals normal sinus rhythms with a rate of 85/min and a markedly enlarged QRS complex in leads V3-V5. Chest x-ray reveals an enlarged cardiac silhouette. A barium esophagram demonstrates a tapering of the distal esophagus that eventually releases as the esophagus is distended. There is no evidence for extrinsic or intrinsic compression of the distal esophagus or an esophageal mass. There is no reflux. The test most likely to lead to a unifying diagnosis in this case is
A. an agglutination test for trypanosomes
B. a chest CT
C. an esophageal manometry
D. a liver biopsy
E. a myocardial biopsy
The correct answer is A. The findings of achalasia and cardiomyopathy in a patient with history of travel to Central or South America support the diagnosis of Chagas disease. This is caused by infection of Trypanosoma cruzi in the muscles of the heart, esophagus, and colon. A serum agglutination test is a noninvasive means of testing for this infection, and is highly sensitive. Left untreated, heart failure and megacolon could develop.

A chest CT (choice B) would not reveal any specific findings of Chagas disease. Using a CT to evaluate for an occult cancer causing esophageal narrowing is superfluous given the findings on the barium esophagram, which is specific for achalasia.

An esophageal manometry (choice C) is a confirmatory test for achalasia. Given the highly suggestive findings of achalasia on the barium esophagram, manometry would not be necessary.

A liver biopsy (choice D) has no role in the evaluation of Chagas disease.

A myocardial biopsy (choice E) is not necessary to diagnose Chagas disease with the availability of the serum agglutination test for trypanosomes. Invasive procedures should be deferred until they are absolutely necessary.

4- A 17-year-old girl is brought to the office by her mother because she has missed “many periods”. The girl admits to binge eating and exercising in order to prevent weight gain. She tells you that she is definitely not pregnant, because she has not had any sexual relations in the past 11 months and thinks she is not getting her menstrual period because of the excessive physical exercise she has been doing in the past several weeks. Physical examination is significant for bradycardia and significant weight loss compared to the last year. A pregnancy test is negative.At this time you should order
A. amylase
B. BUN and creatinine
C. liver function tests
D. serum potassium
E. thyroid function tests
The correct answer is D. Bulimic patients frequently engage in compensatory behaviors to prevent weight gain. Those include self-induced vomiting, abuse of diuretics, laxatives, enemas, or diet pills. The metabolic disorders frequently seen in these patients are, mostly hypokalemia and hypomagnesemia.

Amylase (choice A) is not a routine test ordered in bulimic patients. If there has been evidence of long starvation and suspicion of other medical conditions, its level might alter.

BUN and creatinine (choice B) can be increased if there are signs of dehydration, secondary to the abuse of diuretics. Otherwise, these values should not be changed significantly.

Liver function tests (choice C) are usually not changed in bulimic patients. They can be ordered to rule out other medical conditions if necessary.

Thyroid function tests (choice E) should be done as a part of regular workup of patients presenting with this clinical picture. It is not, however, the first to be ordered.

5- A 76-year-old woman is brought to the hospital by her son because of "rapid breathing." She has advanced Alzheimer disease and is unable to give a coherent history. She was recently diagnosed with breast cancer. She lives alone, but normally has a health care aide during the day. The aide was not available when the son tried to reach her to ask if anything happened. The son has not seen his mother in 2 months. An accentuated fall in systolic blood pressure during inspiration would most likely suggest
A. anxiety
B. cardiac tamponade
C. myocardial infarction
D. senile aortic stenosis
E. sepsis
The correct answer is B. This question describes pulsus paradoxus, which is when there is an accentuated fall in systolic blood pressure (>10 mm Hg) during inspiration. There is usually a small decrease in blood pressure during inspiration, but it is exaggerated in cardiac tamponade because the external compression caused by fluid accumulation around the heart leads to impaired ventricular filling, reduced left ventricular stroke volume, and a reduction in systolic blood pressure. Cardiac tamponade can occur acutely after trauma or develop chronically from the accumulation of pericardial fluid malignancies (she has breast cancer), uremia, infections, collagen vascular diseases, or radiation.

All of the other choices, anxiety (choice A), myocardial infarction (choice C), senile aortic stenosis (choice D), and sepsis (choice E), may be associated with tachypnea, but are not usually direct causes of pulsus paradoxus.

*** A 5 y/o boy is brought to the clinic because of a fever for 5 days and a sore throat and malaise. The mother tells you that he is usually a very healthy child and he is up to date on all of his immunizations. Besides the mother, he lives at home with an older brother and sister, neither of them are sick. On P/E, T=39.5 C (103.1 F), he has a peeling rash on his extremities, one 2 cm lymph node on the right anterior cervical chain, a confluent truncal rash, and mild conjunctivitis. Appropriate management is taken. The most important long-term Mx of this child is:
A. antibiotic prophylaxis to prevent rheumatic fever
B. echocardiograms to look for coronary artery aneurysms
C. excisional biopsy and surveillance of lymph nodes for malignancy
D. nothing, as this is a case of scarlet fever and he will completely recover
E. serial lumbar punctures
The correct answer is B. The vignette demonstrates a case of Kawasaki disease which is characterized by high fever for >5 days, unilateral cervical lymph node, macular papular rash to truck, peeling of hands and feet, and conjunctivitis. The most important sequela of Kawasaki is the development of coronary aneurysms, and so children need to be monitored with EKGs and echocardiograms for at least 2-3 months after the acute illness. Aneurysms form from 7-45 days after illness onset.

Streptococcal pharyngitis is characterized by erythema of the oropharynx, palatal petechiae, and cervical lymphadenopathy. There is no peeling, rash or conjunctivitis. Antibiotics are used for treatment and rheumatic fever prophylaxis (choice A).

The enlarged lymph node is a reactive lymphadenopathy and need not be biopsied or excised (choice C). Upon proper treatment for KD, lymphadenopathy regresses.

This is not a case of scarlet fever (choice D) which is characterized by exanthem and a fine, sandpapery rash, and is usually caused by Streptococcus.

Although children with KD often present with a toxic appearance, lumbar punctures (choice E) is not the standard of care and need not be performed.

*** A 57-year-old woman with a long history of Crohn's disease comes to the office because of slowly progressive ataxia and paresthesias. She is currently off all medications. Physical examination shows a decreased vibratory and positional sense and mild ataxia. A CT of the head is unremarkable. Laboratory studies show:

You suspect B12 deficiency secondary to Crohn's disease. A Schilling test is performed. You expect the study to show:
In order: Radiolabeled Vitamin B12 urinary excretion, Radiolabeled B12 excretion after intrinsic factor added , Radiolabeled B12 excretion after intrinsic factor + antibiotics
A. Normal / Normal / Normal
B. Low/ Normal/ Normal
C. Low /Low/ Low
D. Low /Low/ Normal
E. Normal /Low/ Normal
The correct answer is C. This patient likely has a lesion in her ileum from Crohn's disease. This is the area where B12 is preferentially absorbed. If there is a lesion in the ileum, the Schilling test will reveal no ability to absorb B12. An understanding of the Schilling test should facilitate answering this question. If B12 deficiency develops, a Schilling test can help to define why this happened. The first step is to saturate the body with B12 by giving a large IV dose of normal B12. Simply, this ensures that any additional B12 absorbed will be excreted in the urine. This patient does not lack intrinsic factor so adding IF will not improve B12 absorption. Additionally, this patient's problem is not the lack of dietary B12, so giving B12 alone could not correct the underlying problem.

*** You are asked to see a 3 wk/o infant in the ED with a 1-day history of fever. The parents measured his temperature because he "felt warm" to them and found a temperature of 38.3 C (101.0 F). He has been feeding normally, taking 2 ounces of formula every 3-4 hours. He had 6 wet diapers the previous day. Examination shows an active infant with a temperature of 38.8 C (101.8 F). His skin perfusion is good and his physical examination, including examination of his tympanic membranes, is normal. There are no ill household contacts. The most appropriate next step is to
A. discharge the patient with close outpatient follow up
B. inquire about the mother's group B streptococcal status at delivery
C. obtain the infant's vaccination history
D. order a urinalysis and, if negative, do blood and CSF cultures
E. send blood, urine, and CSF cultures and begin empiric intravenous antibiotic therapy
The correct answer is E. There is absolutely no way to reliably distinguish a self-limited viral illness from sepsis or meningitis in an infant less than 4-weeks of age. Accordingly, all infants with a fever greater than 38 C (100.4 F) in this age group require full evaluation, including admission and parenteral antibiotics. The incidence of sepsis is somewhere between 5-10% with this degree of fever and can be catastrophic if missed, resulting in death or permanent neurologic disability.

Discharging the patient (choice A) is inappropriate because well-appearing infants in this age group may still have a potentially lethal bacterial disease.

At 3 weeks, this infant is at the peak incidence of late onset group B streptococcal disease, but the mother's group B streptococcal status (choice B) does not correlate well with occurrence of late onset group B streptococcal disease and so it is not relevant here. Maternal group B streptococcal screening is useful in the management of early-onset disease (disease within the first few days of life).

At 3 weeks this infant is unlikely to have received any vaccinations (choice C), with the possible exception of hepatitis B vaccine. He would not in any case have received Haemophilus influenzae or conjugated Streptococcus pneumoniae vaccine, which are the only two that could potentially influence his susceptibility to sepsis or meningitis.

Urinalysis (choice D) is not reliable in excluding urinary tract infection in very young infants, and therefore is not a good screening test to decide if further evaluation is necessary.

*** A 30 y/o woman is brought to the emergency department after a high-speed MVA in which she was an unrestrained driver. She was conscious at the scene with a Glasgow Score of 13. There were beer bottles evident in the car. On arrival at the emergency department, primary survey shows an abdominal bruise on the RUQ. Her vital signs are stable and blood alcohol level is 2449 mg/dL. Her PMH is remarkable for alcoholic pancreatitis twice in the previous 3 years. The patient complains of marked right upper quadrant pain and has significant tenderness on palpation of her right upper and right lower quadrants. An abdominal CT scan shows pericholecystic fluid and possible gallbladder wall thickening. The most appropriate next step to diagnose possible gallbladder rupture is:
A. diagnosis can be made by CT scan alone
B. ERCP
C. HIDA scan
D. exploratory laparoscopy
E. exploratory laparotomy
The correct answer is D. This patient has suffered a traumatic injury to her right upper quadrant and there is a clinical suspicion of gallbladder rupture. The gold standard for such a diagnosis is direct visualization. Since laparoscopy is widely available, it has become the modality of choice to undertake direct visualization of the suspected injury.

The diagnosis cannot be made by CT alone (choice A). The CT shows only pericholecystic fluid. This is consistent with chronic or acute cholecystitis, both of which are a possibility given her history of alcohol use and pancreatitis. The issue, given her trauma, is whether the gallbladder has ruptured.

An ERCP (choice B) is an endoscopic diagnostic and therapeutic tool for the management of biliary disease. It has no role in the diagnosis of gallbladder rupture. It can however be used to demonstrate gallbladder filling with contrast after the removal of biliary stones.

A HIDA scan (choice C) is an imaging modality utilizing radioactive tracers to visualize the gallbladder. However, given the widespread use of laparoscopic equipment, this test has been largely supplanted by the new, more sensitive diagnostic laparoscopy.

Exploratory laparotomy (choice E) has attendant intra- and postoperative complications that make it largely reserved for centers where laparoscopy is not available. It is also reserved for patients with extensive abdominal trauma or clinical signs and symptoms consistent with massive abdominal pathology where laparoscopy would not be useful or for patients that require a laparotomy for another indication.

*** A 64 y/o man comes to the clinic because of a "spot" on the side of his face that has been there for about 8 months. He says that he is an executive at a local company and is retiring at the end of the year. The company has hired a portrait artist to paint his picture that will hang in the boardroom for many years to come, and so he realized that this is a good time to "have this thing taken off." He thinks that the lesion has not grown since he noticed it, but he has not paid it much attention. He plays tennis every weekend at his country club and then lies in the sun with his wife. This is the first time you have seen this patient, but he tells you that he has been very healthy and has only suffered through "a couple of bouts of kidney stones" over the years. Physical examination shows a 2.3-cm waxy, verrucous, dark brown papule with a “stuck-on” appearance.The most likely diagnosis is
A. actinic keratosis
B. basal cell carcinoma
C. dermatofibroma
D. melanoma
E. psoriasis
F. seborrheic keratosis
G. squamous cell carcinoma
The correct answer is F. This patient most likely has seborrheic keratosis. This lesion is characterized by light brown to black papules or plaques with an adherent waxy, greasy scale. The "stuck-on" appearance is very characteristic. It is most often found on the face and trunk.

A 35 y/o white female is brought to your office after a brief loss of consciousness. No tonic-clonic activity was observed, nor did the patient experience urinary incontinence. She recalls that about 10 seconds prior to blacking out she felt nauseated, began sweating, and became pale. When she recovered, she had no memory loss or confusion. Her physical examination, including a thorough neurologic examination, is unremarkable. A CBC, blood profile, and EKG are all within normal limits. Appropriate management at this time would include
a.an EEG
b.24-hour Holter monitoring
c.echocardiography
d.a CT scan of the head
e.reassurance

e- Patients with vasovagal syncope often present with prodromal symptoms such as nausea, diaphoresis, pallor, and lightheadedness. This often occurs in stressful or frightening situations. These premonitory symptoms often occur before the loss of consciousness. A quick recovery of mental function after an episode of loss of consciousness makes it much more likely that this was a syncopal episode rather than a seizure, as seizures are often followed by a postictal period of residual confusion. A patient does not always have to experience tonic-clonic movements for the diagnosis to be a seizure disorder, since brief tonic-clonic movements can be seen in some syncopal episodes. However, patients who experience an aura or incontinence of urine or feces often have had a seizure.

For a pregnant woman in the 26th week of gestation who tested positive for Streptococcus B you should start the treatment:
a.right away
b.one week before delivery
c.24 hours before delivery
d.during delivery

d- Physicians who culture for GBS carriage during prenatal visits should do so late in pregnancy (35-37 weeks’ gestation); cultures collected earlier do not accurately predict whether a mother will have GBS at delivery.

You diagnose acute pancreatitis in a 45-year-old white male. As you initiate therapy and closely monitor his progress, which one of the following complications is most likely to develop?
a.Hypomagnesemia
b.Hypoglycemia
c.Hypercalcemia
d.Acute hypertension

a- Treatment strategies for pancreatitis vary somewhat and are related to the degree of inflammation. In patients with mild pancreatitis, a therapeutic regimen of avoidance of oral intake, intravenous hydration, and analgesia usually suffices.
However, patients with more severe pancreatitis are likely to develop significant complications, and require closer monitoring. Patients with hypotension and vascular instability frequently require massive fluid resuscitation. Patients with metabolic complications such as hyperglycemia, hypocalcemia, or hypomagnesemia may require insulin, calcium, or magnesium supplementation.

Immediate gastric lavage is contraindicated in treating acute ingestion of which one of the following?
A.Salicylates
B.Strychnine
C.Ethanol
D.Acetaminophen
E.Phenothiazines

b- Ten to 30 minutes after ingestion of strychnine, untoward symptoms begin. Often without any warning the patient falls into violent convulsions. Gastric lavage is postponed until treatment designed to prevent the convulsions is started. Initiation of gastric lavage as soon as possible is indicated in treating poisoning by salicylates, ethanol, acetaminophen, and phenothiazines.

Which one of the following depressed patients is most likely to commit suicide?
a.A 26-year-old male who repeatedly denies any thoughts of suicide
b.A 30-year-old female who has been hospitalized overnight on several occasions for attempted suicide
c.A 50-year-old recently divorced alcoholic male who feels life is hopeless
d.A 50-year-old female who thinks of suicide and fears she might act on her thoughts

c- Assessment of suicidal risk is critical in determining the need for and duration of hospitalization of depressed patients. Most suicides are planned, not impulsive, and carried out successfully most often by the elderly, males, those in poor health, alcoholics, schizophrenics, those who have recently lost a loved one (especially a mate), and those suffering from depressive disorders. Many depressed patients think about suicide, and a physician should take these patients seriously; however, among this group of patients, the 50-year-old recently divorced alcoholic male has the highest risk of successful suicide.

Which disease could be with higher BP in lower extremity than in upper extremity?
TAKAYASO: High in the lower

A 70-year-old former shipyard worker, who smokes one pack of cigarettes daily, notes progressive weight loss and debility over a period of 6 months. Over a period of 1 month, he develops right chest pain and a nonproductive cough. A chest x-ray reveals extensive pleural thickening, pleural effusion, and hilar adenopathy. A pleural biopsy confirms mesothelioma. Which of the following is a favorable prognostic factor in this patient?
a. Male sex
b. Extent of disease at diagnosis
c. Good performance status
d. Pain as presenting symptom
e. Age over 65
f. None of the above

f- All of the clinical components noted exhibit very poor prognostic factors in the patient with mesothelioma, a particularly aggressive disease that remains unresponsive to many forms of aggressive therapy.

Which one of the following has proven most useful for breast cancer screening in women who have had silicone breast implants?
a.Thermography
b.Ultrasonography
c.Mammography
d.Magnetic resonance imaging

c- Screening by conventional film-screen mammography, supplemented by the displaced or Eklund view, is the recommended method for breast cancer screening in women with breast implants. The displaced view draws the breast forward while placing the implant posteriorly, increasing the amount of breast tissue visualized. None of the other modalities has proven useful for screening asymptomatic women for breast cancer.

The answer is A
In the case described, the osmolality of fecal water is approximately equal to serum osmolality. Furthermore, there is no osmotic "gap" in the fecal water; the osmolality of the fecal water can be accounted for by the stool electrolyte composition: {2 × [(Na+) + (K+)]} = [2 × (39 + 96)] = 270. A villous adenoma of the colon typically produces a secretory diarrhea. Lactose intolerance, nontropical sprue, and excessive use of milk of magnesia produce osmotic diarrheas with osmotic "gaps" caused by lactose, carbohydrates, and magnesium, respectively. Pancreatic insufficiency causes steatorrhea, not watery diarrhea.

A 60-year-old white female is scheduled to have a total abdominal hysterectomy. She is currently in good health, but the general surgeon is concerned because the patient had a pulmonary embolus 10 years ago.Which one of the following is most effective for prevention of another embolus?
a.No prophylaxis necessary
b.Impedance plethysmography, 36 and 72 hours after surgery
c.Aspirin prophylaxis
d.Full heparinization after surgery
e.Subcutaneous heparin prophylaxis

e- This patient is considered at high risk for a venous thromboembolism because of general surgery, age greater than 40, and previous history of a pulmonary embolus. In numerous clinical trials, heparin, 5000 U subcutaneously 2 hours prior to surgery, followed by 5000 U subcutaneously every 8 to 12 hours until the patient is ambulatory, has statistically reduced the incidence of deep vein thrombosis. Full heparin therapy is not necessary. Aspirin is not effective, and impedance plethysmography would not prevent thrombosis.

An obviously intoxicated 50-year-old white male is brought to the emergency department after the car he was driving hit a telephone pole. He has a fracture of the femur, and is confused and uncooperative. He is hemodynamically unstable. Initial physical examination of his abdomen does not indicate significant intra-abdominal injury.
Which one of the following would be best for determining whether laparotomy is needed?
a.Peritoneal lavage
b.Contrast duodenography
c.Ultrasonography of the abdomen
d.An MRI scan of the abdomen
e.A CT scan of the abdomen

a- Physical examination of the abdomen is often unreliable for detecting significant intra-abdominal injury, especially in the head-injured or intoxicated patient. In a hemodynamically unstable patient with a high-risk mechanism of injury and altered mental status, peritoneal lavage is the quickest, most reliable modality to determine whether there is a concomitant intra-abdominal injury requiring laparotomy. Computed tomography of the abdomen and contrast duodenography may complement lavage in stable patients with negative or equivocal lavage results, but in an unstable or uncooperative patient these studies are too time-consuming or require ill-advised sedation. Ultrasonography may also complement lavage in selected patients, but its usefulness is limited in the acute situation. Magnetic resonance imaging is extremely accurate for the anatomic definition of structural injury, but logistics limit its practical application in acute abdominal trauma.

A 67-year-old white male retired factory worker was found to have an abdominal aortic aneurysm on routine physical examination. A vascular surgeon has recommended operative repair. The patient is a former smoker, with a 10-pack-year smoking history. Three years ago, while under the stress of a forced retirement, he had angina which responded well to sublingual nitroglycerin. He has had no angina for 1 year.
Which one of the following conditions would be the most likely cause of perioperative death in this patient?
a.Pulmonary complications
b.Peripheral embolization
c.Operative site infection
d.Myocardial infarction
e.Cerebral infarction

Answer is d. Myocardial infarction is the major cause of perioperative death in patients undergoing surgery for abdominal aortic aneurysm. This is especially true of patients with a history of known coronary artery disease or with EKG abnormalities, and it is true even if the coronary artery disease is stable.
Cerebral infarction occurs infrequently, even though cerebral vascular disease is commonly present in this patient group. Operative site infection, peripheral embolization, and pulmonary complications are all significant postoperative complications which may cause death, but they are less frequent causes of death than myocardial infarction.

Which one of the following is true of a pregnant patient who has diabetes mellitus?

a. Adjustments in hypoglycemic medications are best made by following urine glucose readings
b. Oral hypoglycemic agents are useful during pregnancy in patients with mild diabetes mellitus
c. A precise knowledge of fetal age is important to a successful outcome for the fetus
d. Because the fetal pancreas helps control the diabetes, ketoacidosis is less likely during pregnancy

c- Ideally, the child of an overtly diabetic woman should be delivered close to term. Precise knowledge of fetal age (by menstrual history, accurate measurements of uterine height during the second trimester, and confirmation by sonography) is very important to a successful outcome for the fetus.

Severe growth retardation is diagnosed in the fetus of a 19 y/o unmarried white female at 36 wks gestation. The Dx is based on biparietal diameter and there is scant amniotic fluid.Which one of the following is the most appropriate management?

b- Appropriate management of the preterm infant who is severely growth retarded depends on several factors. Generally those near term should be delivered promptly. By the time that growth retardation has become severe, the fetus is usually mature enough to survive if delivered promptly. However, the fetus must be monitored carefully during labor, with facilities for immediate cesarean section if there is deterioration, and the neonate must receive excellent neonatal care beginning immediately after delivery.

A 53 y/o woman presents with a long Hx of dyspepsia, fullness, and belching. An endoscopy shows severe antral erythema and a small hiatal hernia, but no ulcer. Because of her long history of dyspepsia, a serum gastrin test and serum IgG test for Helicobacter pylori are done. The serum gastrin test result is 1800 pg/mL and the test for H. pylori is negative. The next test that should be done in this patient is:
a- push enteroscopy
b- secretin stimulation test
c- gastric acid level messurement
d- pancreas angiography
e- endoscopic US

answer is c. the finding of a high serum gastrin concentration is not infrequently a reason for referral for tests to diagnose Zollinger-Ellison syndrome, she does not have any of the features of the ZE, (recurrent multiple peptic ulcers and/or diarrhea). The first test that should be done is to assess whether the patient has hyperchlorhydria or hypochlorhydria by inserting a NGT and measuring basal acid secretion. However, some of the highest serum gastrin concentrations are found in patients with achlorhydria or hypochlorhydria due to gastric atrophy (for example, in pernicious anemia or after the prolonged use of antisecretory drugs, particularly proton-pump inhibitors).

A 42 y/o female with Hx of 3 spontaneous abortions presented with pain in the left leg, which later on Dx of DVT was confirmed. Which of the following findings is most likely in the laboratory results of this patient?
A - Polycytemia
B - Thrombocytopenia
C - Low white blood cell count
D - Hyponatremia
E – Hyperkalemia

A 53 y/o male smoker presented with a 2 wk Hx of expectorating sputum streaked with a blood. He denies any fever or chills or increases in the intensity of his cough. P/E and CXR are unremarkable. Which of the following is an appropriate next step in the diagnostic work-up of this patient?
A - Fiberoptic bronchoscopy
B - MRI of the chest
C - High resolution CT of the chest ( HRCT )
D - A and B
E - A and C

Answer is E. Fiberoptic bronchoscopy and HRCT are complementary to each other. HRCT can demonstrate all tumors seen on bronchoscopy as well as several which are beyond bronchoscopic range. On the other hand, HRCT could not detect bronchitis or subtle mucosal abnormalities that could be seen on bronchoscopy. Also, HRCT is particularly useful in diagnosing bronchiectasis and aspergillomas, while bronchoscopy is diagnostic of bronchitis and mucosal lesions such as Kaposi’s sarcoma. The patient in question is at high risk for pulmonary carcinoma; as of today, the procedures are considered complementary in this setting.

A patient with cytomegalovirus retinitis has been treated with IVganciclovir for the last 4 months. On the most recent lab findings a sudden drop in the plt count was noted (20,000 mm3). Which of the following is the most appropriate action in this situation?
A - Discontinuation of the therapy
B - Exchange of ganciclovir with intravenous foscarnet
C - Exchange of ganciclovir with acyclovir
D - Exchange of ganciclovir with valcyclovir
E - Continuation of ganciclovir therapy

Answer is B. The major drugs that are used for treatment of CMV retinitis are IVganciclovir and foscarnet, oral ganciclovir, intraocular ganciclovir, and IV cidofovir. Ganciclovir and foscarnet have equivalent efficacy against the retinitis. Major side effects of the ganciclovir are neutropenia and thrombocytopenia (limiting use in up to 16% of patients). Ganciclovir should not be given with absolute neutropenia of less than 500 mm3 and thrombocytopenia 25, 000 mm3.

A 76 y/o man is hospitalized with stroke in the area of the right middle cerebral artery. He had a paroxysm of cough immediately after attempt to eat.On P/E he is alert and oriented to time, place, and person. He has severe dysarthria but no signs of aphasia. He has facial asymmetry due to Lt sided facial droop, but his gag reflex is intact. Which of the following is the most appropriate way to provide nutrition to this patient?
A - Placement of a percutaneous gastrostomy tube
B – IV alimentation
C - Feeding through a NGT
D - Oral feeding supervised by a nurse and suctioning as needed
E - Clear liquid diet with advanced diet as soon as possible depending on patient’s clinical status

Answer is B. After a stroke about 25-45% of all patients develop dysphagia. The main problem that stems from dysphagia is aspiration pneumonia, which, if it develops, greatly complicates the clinical course and contributes to mortality. The patient in question had an attack of cough after an attempt to eat. This is a common sign of dysphagia. Physical examination of this patient revealed several findings that suggest dysphagia (facial nerve paresis and dysarthria). It is a common misconception that presence or absence of a gag reflex correlates with the risk of aspiration. This is not true. More important in the assessment of the aspiration risk are speech articulation, ability to swallow, and tongue movement.

A 16 y/o male in good health presents to you for a school physical. His family hx reveals that his father died of colon cancer at age 37. Your physical exam reveals a healthy young man with several lipomas on his back and legs and a nodule on his jaw. You should:
a. Suggest colonoscopy at age 30.
b. Suggest colonoscopy now.
c. Suggest flexible sigmoidoscopy and barium enema at age 30.
d. Suggest flexible sigmoidoscopy and barium enema now.
e. Biopsy his jaw lesion.

Answer is D. case of Gardner’s Syndrome.

An elderly male complains of severe muscle weakness in his thigh muscles and proximal arm muscles, although this weakness is mild. He states that his weakness is worse in the morning immediately after getting out of bed and improves during the day.
On P/E, it is apparent that muscle strength increases with repetition of the grip strength test and later diminishes. Which of the following tests should be included in the workup of this patient?
A - CXR
B - Tensilon test
C - Abdominal CT
D - Colonoscopy
E – Cystoscopy

Answer is A. Symptoms in this man are consistent with Eaton-Lambert syndrome. This syndrome shares the same pathologic site with myasthenia gravis (the neuromuscular junction) and has a similar path physiology (an autoimmune disease). Eaton-Lambert syndrome is usually associated with malignancy. Up to 70% of these patients have associated small cell lung cancer, and this disease must be ruled out in every patient with presenting symptoms of Eaton-Lambert syndrome.
Clinical presentation of the Eaton-Lambert syndrome includes weakness that is typically seen early in the hip girdle, making it difficult for the patient to rise from a chair or to climb the stairs. Less dramatic is shoulder girdle weakness. Involvement of the bulbar muscles or diplopia is rare, but ptosis is frequently seen. Symptoms are also likely to be more prominent in the morning; autonomic dysfunction may cause erectile dysfunction and dry mouth.
Differentiation from myasthenia gravis may be hard since patients with Eaton-Lambert syndrome have a positive AChR-Ab test in 13% of cases.

A 50 y/o man presents to the ER complaining of 6 hours of severe diarrhea. He has had eight to ten liquid stools, without blood. He has diffuse cramping abdominal pain alleviated by each bowel movement, but he denies tenesmus. He has mild untreated hypertension but no other medical problems. He denies recent travel. Other family members have not been ill. Vital signs: PR= 94/min, BP= 148/96 mm Hg, no changes with standing, T= 37 °C (98.6 °F). The P/E is normal. The best initial approach to this patient is:
(A) Obtain stool specimens for culture, examination for fecal leukocytes, and examination for ova and parasites
(B) Empiric antidiarrheal therapy
(C) Empiric antibiotic therapy with trimethoprim–sulfamethoxazole or ciprofloxacin
(D) Reassurance and oral fluids
(E) Flexible sigmoidoscopy with mucosal biopsy

Answer is D. This patient has an acute diarrheal illness without evidence of severe inflammation, dehydration, or other risk factors. The great majority of acute diarrheal illnesses are infectious (viral or bacterial) and self-limited. Oral hydration and reassurance are the most appropriate care for such patients. If the diarrhea persists or if the patient develops a more toxic clinical picture, additional diagnostic tests would be indicated. At the time of presentation, stool studies are not helpful. Empiric therapy with antibiotics is not indicated. Flexible sigmoidoscopy is indicated only in persistent or inflammatory diarrhea.

A 9 y/o girl is brought to the clinic because she has felt "sick" and has been unable to go to school for the past 2 days. She complains of a headache, congestion, rhinorrhea, and double vision. Her PMH is remarkable for recurrent otitis media 2 years ago for which she eventually received bilateral myringotomy tubes. She lives at home with her mother and grandmother who are both cigarette smokers. T=38.8 C (101.8 F), PR=120/min, RR=20/min, and visual acuity is 20/20 in both eyes. P/E shows tympanic membranes with evidence of previous surgery, but are otherwise normal, an erythematous oropharnyx with exudation, and slight exophthalmos of the left eye. On the left, the ocular examination also demonstrates periorbital edema, injection of the conjunctiva, trace restriction of extraocular movements, and an afferent pupillary defect. The right eye is normal. The rest of her physical exam is unremarkable. What’s the best next step in Mx?
A. A CT of the head
B. Gentamycin eye drops treat most cases, but patients need close observation
C. Hospitalization and IV antibiotics are indicated
D. Oral antibiotics are the first line of treatment
The correct answer is C. This patient has orbital cellulitis. Patients present with lethargy, fevers, signs and symptoms consistent with sinusitis, proptosis of the globe, restriction of extraocular movements, periorbital edema, injected conjunctiva, and afferent pupillary defects. Hospitalization and IV therapy should be started at once as this condition is potentially fatal, especially if the cavernous sinus becomes involved.

A 37 y/o woman with a history of bipolar disorder is brought to the ER by ambulance obtunded and ataxic. The patient has not been hospitalized in over 5 years and has been stably maintained on outpatient therapy with a regimen of lithium carbonate 600 mg by mouth twice a day. While you are examining her, she has a tonic-clonic seizure lasting approximately 30 seconds. As part of the laboratory work-up, the patient's lithium level is found to be 4.2 mEq/L. After basic airway and cardiovascular support, the most appropriate next step in this patient's management is to:
A. administer a loading dose of phenytoin
B. get a renal consultation for emergent dialysis
C. order an MRI of the patient's head
D. provide conservative management including fluid and electrolyte replacement
E. send liver function tests

The correct answer is B. The patient presents to the ED with potentially life-threatening lithium toxicity. The treatment of choice for lithium levels greater than 4.0 mEq/L is hemodialysis.

A 16 y/o girl is brought to see you by her mother, who is a nurse in your office. The patient is hoping to play for the school volleyball team and needs a clearance form signed by a doctor. Her past medical history includes exercise-induced asthma and allergic rhinitis for which she takes albuterol and loratadine. During the interview with the patient, while you are speaking with her alone, she reveals that she has been sexually active with her boyfriend for the last 2 years. She has not yet discussed this fact with her parents. Her physical examination, including pelvic exam, is normal. At this time the patient should be screened for :
A. chlamydia
B. gonorrhea
C. hepatitis B
D. HIV
E. herpes simplex
F. syphilis
The correct answer is A. Routine screening for chlamydia in all sexually active women aged 25 and younger, as well as in asymptomatic women older than 25 who are at high risk is recommended.

An 18 y/o boy is brought to the ED by ambulance. He and his friends were ice-skating on a frozen pond when the ice broke and the young man became submersed in cold water. His friends admit to drinking alcohol prior to the incident. The patient's rectal T=33 C (91.4 F), PR= 57/min & weak, BP= 80/30 mm Hg, and RR= 7/min. P/E reveals a comatose young man. An EKG is most likely to show
A. delta wave
B. diffuse broadening of T waves
C. prominent U waves
D. shortened QT intervals
E. upward deflection following the S wave

The correct answer is E. Hypothermia prolongs repolarization causing an upward deflection following the S wave (distinctive convex elevation of the J point), which is usually called an Osborn wave (or J wave of Osborn).

A 71 y/o woman is brought to the physician by her distressed daughter. The daughter relates that, 3 days ago, her mother began to complain of RUQ abdominal pain and then she complained of chills, nausea, and some vomiting. On P/E reveals an obtunded, hypotensive, and obviously very sick elderly woman. She has impressive pain to deep palpation in theRUQ, along with muscle guarding and rebound. T= 40 C (104 F). Lab results :
WBC= 22,000/mm3 with multiple immature forms,
bilirubin= 5 mg/dL and
Alk Ph= 840 U/L.
serum amylase= normal.
An emergency sonogram shows multiple stones in the gallbladder, normal thickness of the gallbladder wall without pericholecystic fluid, dilated intrahepatic ducts, and common duct with a diameter of 2.1 cm. The sonographer cannot identify stones in the common duct. In addition to IV fluids and antibiotics, which of the following is the most appropriate next step in management?
a- Elective cholecystectomy
b- Emergency decompression of the common duct
c- Emergency cholecystectomy
d- Emergency surgical exploration of the common duct
e- Emergency transhepatic cholecystostomy

The correct answer is B.
The Dx is acute ascending cholangitis. This deadly disease is seen in patients with long-standing gallstones who get one or more stones in the common duct, where they produce partial obstruction that allows ascending infection. The chills, very high fever, and extremely elevated alkaline phosphatase are diagnostic. The key component of therapy is immediate decompression of the common duct, which is full of pus. How it is achieved is less important. ERCP is usually the first choice, but it can be done by PTC or by open surgery.

A 6 month old child falls and hits his head. Which of the following signs would be the MOST indicative of serious neurological injury?
a- The parent states the child was pale and sweaty for a few minutes after the fall
b- A single post-fall episode of emesis
c- Lethargy immediately after the head injury
d- Hypotension
e-A single grand mal seizure immediately after the fall

Infrequently, infants become hypotensive from blood loss into either the subgaleal or epidural space after head trauma. Hypovolemia can occur because of open cranial sutures and fontanelles. Transient paleness, lethargy, diaphoresis, and emesis are common after minor head trauma and do not necessarily signify significant neurological injury. Persistence of any of these signs or symptoms, or change in mental status is concerning. Seizures may occur shortly after head injury and are usually self-limited. However, about 50 percent of patients with posttraumatic seizures have positive findings on head computed tomography (CT). Children with two or more seizures or a GCS < 8 should be strongly considered for anticonvulsant therapy.

Which of the following drugs is NOT associated with acute pancreatitis?
(A) Heparin
(B) Furosemide
(C) Rifampin
(D) Salicylates
(E) Warfarin

The answer is A. Drugs and toxins are major causes of acute pancreatitis. Some of the medications associated with the occurrence of acute pancreatitis are oral contraceptives, estrogens, phenformin, glucocorticoids, rifampin, tetracycline, isoniazid, thiazide diuretics, furosemide, salicylates, indomethacin, calcium, warfarin, and acetaminophen. Other etiologic factors contributing to the development of pancreatitis include infection, collagen vascular disease, metabolic disturbances, and trauma.

An 11 y/o boy is rushed into the ED following a MVA. The patient was a restrained, front seat passenger, when an oncoming car hit the passenger side of the car. The boy denies loss of consciousness, but in the hospital he complains of pain over his right side. His BP=118/59, PR=139/min, and RR=24/min. On P/E, he has decreased breath sounds over the right base, and there is ecchymosis over the right flank. His abdomen is soft with tenderness in the RUQ. Appropriate Mx of his airway with neck stabilization is provided and he is resuscitated appropriately. Imaging studies of his neck are negative and a CXR does not show pneumothorax or rib fractures. Dipstick of spontaneously voided urine is positive for blood. U/A confirms the presence of 50 RBC/hpf. In regards to his hematuria the next most appropriate course of action is to:
A. begin empiric antibiotic therapy
B. obtain a CT scan of abdomen and pelvis
C. order a renal/bladder ultrasound
D. perform a retrograde urethrogram
E. place a Foley catheter
F. repeat the urinalysis
G. schedule an outpatient intravenous pyelogram (IVP)
The correct answer is B. obtain a CT scan of abdomen and pelvis.
The management of hematuria associated with trauma differs in adults and children. In the adult population, imaging is performed only in those patients with gross hematuria or microscopic hematuria plus hypotension. This differs from the pediatric patient. In children, any degree of hematuria (gross or microscopic) should be investigated with imaging studies. One reason for this discrepancy is that large amounts of catecholamines released in injured children may sustain blood pressure in the face of hypovolemia. A CT scan is the most useful imaging modality in this setting. A CT scan is noninvasive, accurate and fast, and it can help in assessing the size and extent of retroperitoneal hematomas and renal parenchymal trauma. Not only does this child have microscopic hematuria (an indication by itself to perform imaging studies), but he also has signs, (flank ecchymosis and tenderness), that raise the suspicion of renal injury. High suspicion for renal injury (i.e., rib fracture, flank contusion, deceleration injury) is another indication for perform imaging studies.

*** A 45 y/o woman presents with acute pancreatitis with a serum amylase concentration of 2010 U/L, T=37.2 °C (99.0 °F), the leukocyte count is 12,000/mL; plasma Glc=250 mg/dL; and serum ca=8.4 mg/dL. She recovers after 1 wk of supportive therapy. No obvious cause for the pancreatitis is found; ultrasonography is normal, and the fasting serum triglycerides are 350 mg/dL. The best course of action to diagnose the cause of the pancreatitis is:
(A) ERCP
(B) No further diagnostic testing until another attack occurs
(C) CT scan with contrast
(D) Measurement of serum CA 19-9
(E) MRI of the pancreas
B- No further diagnostic testing until another attack occurs
The best course of action in a patient with a first attack of relatively mild pancreatitis even with a high serum amylase concentration is to see whether further attacks occur before continuing invasive investigations. The presumption is either that the patient has passed a small single gallstone or that the cause has not yet been identified, that is, it is “idiopathic pancreatitis.” The latter is often a once-only disease, and therefore no further investigations are warranted at this time. An ERCP and CT scan or MRI would be indicated after recurrent mild attacks or two severe attacks to try to establish a diagnosis, particularly common duct stones or pancreas divisum. Measurement of CA 19-9 is not indicated.
Although a full lipid workup in this patient would be good medicine and should be done in any case (and may also be an indirect evidence of gallstones), it is unlikely to be the cause of pancreatitis. Hyperlipidemic pancreatitis is unusual if lipid levels are less than 600 mg/dL. After an initial severe attack, some authorities would do a repeat ultrasound within 3 to 6 months just to exclude gallstones.

***1- An African- American couple with no known family hx of sickle cell dis., want to know what the chance is that their child have sickle cell dis. To obtain a more accurate assessment, RBC electrophoresis of the couple was done. The male has no HbS, but the female has a clear HbS band. Knowing that the carrier rate among African-Americans is approximately 8%, or 1 in 12, the chance that their child will have sickle cell dis. Is most likely which of the following?
a- 0
b- 1/144
c- 1/288
d- 1/576
e- 1/1936

2- If there was no information about the parent electrophoresis, what would be the chance of the child having the dis.?
a- 0
b- 1/144
c- 1/288
d- 1/576
e- 1/1936

1- a- 0, 2- d- 1/576
Px with sickle cell dis., are homozygous for the HbS. Because only one potential parent has the HbS allel, the only way their child could inherit two HbS genes is if the father’s sperm underwent a new mutation, which is an extremely unlikely event. Therefore, their child does not have a chance of inheriting the dis. Howerever, there’s a chance of ¼ that their child would be a carrier, having only the sickle cell trait.
With no information, the odds that two carriers will meet is 1/12 x 1/12= 1/144, and the odds that two carriers will have an infected child is ¼, so, the odds that two Africa-americans will have a child with dis. is 1/144 x ¼= 1/ 576

***A 28 y/o woman, G4P4, at 28 wks gestation, presents for prenatal visit. She says that she has not felt the baby move for 2 days. She has a Hx of HTN, which she’s being treated with alfa methyl dopa, BID. On P/E, BP= 145/85, fundal height at 30 cm, and baby’s in transverse position. No FHR was detected with Doppler feotoscope. What’s the next step of Mx ?
a- Perform a NST
b- Perform an amniocentesis
c- Obtain real-time US for cardiac motion
d- Obtain a maternal abd. x-ray for fetal assessment
e- Obtain a quantitative beta HCG
f- Observation and check up in 2 wks

Answer is c- Obtain real-time US for cardiac motion
It’s the method of choice for fetal death.

Answer is c- adrenoleukodystrophy which is an x-linked dis. that affects young males, usually begin at 7-8 yrs of age. It’s characterized by demyelination of the CNS, adrenal insufficiency, mental deterioration, aphasia, apraxia & dysarthria. 1/3 of patients have loss of vision also.

*** An elderly Px developes painful swelling of Rt. parotid gland 10 days after cholecystectomy. This is most likely secondary to which of the ffg ?
a- Staph. Aureus
b- Duct obstruction by a stone
c- A viral infection
d- Hemorrhage
e- An immunologic reaction

Answer is a- staph aureus.
The px most likely has acute surgical parotitis ( sialadenitis ), which usually occur 1 wk post op in elderly patients who have poor dental hygiene and have intubated. Staph aureus is the most common organism. Tx is surgical drainage & antibiotics.

Answer is D- nuclear medicine scintigeraphy
There are no specific signs and symptoms of delayed gastric emptying, and when this disorder is suspected, the diagnosis of gastroparesis can usually be made by various diagnostic methods.
The presence of retained food in a dilated stomach at the time of upper gastrointestinal contrast studies or detected endoscopically is indicative of underlying motor dysfunction when mechanical obstruction has been excluded. However, some patients with decreased motility of the stomach may not exhibit retained food.
Ultrasonography has been used to determine the emptying rate for liquids and appears to be relatively accurate, but gastric scintigraphy of either solid or liquid test meals labelled with a radiopharmaceutical has proven to be the most accurate method of detecting underlying gastric motility abnormalities. Gastric scintigraphy supplies a quantitative result and can be used to evaluate the response to therapy. Electrogastrography is a research tool and its clinical application is unclear.

A 53 y/o alcoholic man with known cirrhosis presents with recent onset of abdominal swelling and fever. On P/E PR=92/min, BP=98/62 mm Hg, T=38.5 °C (101.3 °F), palmar erythema, spider angiomata, moderate abdominal swelling with bulging flanks, and a liver span of 8 cm are noted. There is no evidence of asterixis. Lab results:
ALT=55 U/L, AST=62 U/L, serum BR=1.3 mg/dl, serum total pr.=7.3 g/dl, serum Alb=3.8 g/dl
Paracentesis reveals 25 mL of straw-colored fluid. Ascitic fluid albumin is 2.9 g/dL; the fluid contains 1000 RBC and 960 leukocytes/microliter, with 90% lymphocytes and 10% PMN. The fluid is negative for amylase, and Gram stain shows no organisms.The most appropriate next intervention is:
(A) Cefotaxime, 1 g every 6 hours intravenously
(B) Laparoscopy with biopsy and culture of peritoneal lesions
(C) CT scan
(D) Norfloxacin for prophylaxis of spontaneous bacterial peritonitis
(E) Exploratory laparotomy
Answer is B- laparascopy ewith Bx & culture of peritoneal lesions
This patient has evidence of chronic liver disease on physical examination. The recent onset of ascites is complicated by fever and an elevated number of ascitic fluid leukocytes with a lymphocyte predominance. The ascitic fluid lymphocytosis is typical of tuberculous peritonitis, peritoneal carcinomatosis, or chylous ascites. In spontaneous bacterial peritonitis, the absolute polymorphonuclear cell count is 250/L and represents over 70% of the total leukocytes.
This patient is at increased risk for tuberculous peritonitis because of the debilitating conditions of alcoholism and cirrhosis. The most sensitive procedure for diagnosing suspected tuberculous peritonitis is laparoscopy with biopsy for culture and histologic examination of peritoneal lesions. This does not require surgical laparotomy. Diagnosis to the underlying cause of fever and ascitic fluid lymphocytosis should take precedence over initiation of diuretic treatment. Cefotaxime therapy is appropriate treatment for spontaneous bacterial peritonitis, which is usually caused by enteric gram-negative organisms or streptococci. Aminoglycosides are to be avoided in these patients because of the risk for precipitating or exacerbating renal insufficiency. After an initial episode of spontaneous bacterial peritonitis, prophylaxis with oral antibiotics that provide selective intestinal decontamination, such as norfloxacin, ciprofloxin, or trimethoprim–sulfamethoxazole, will considerably reduce the incidence of recurrent peritonitis. CT scan is insensitive for diagnosis of infection and is most useful for detecting malignancy, which is not likely in this patient.
CMDT:
Fever may suggest infected peritoneal fluid, including bacterial peritonitis (spontaneous or secondary). In immigrants, immunocompromised hosts, or severely malnourished alcoholics, tuberculous peritonitis should be considered.
The accuracy of the SAAG exceeds 95% in classifying ascites. It should be recognized, however, that approximately 4% of patients have "mixed ascites," ie, underlying cirrhosis with portal hypertension complicated by a second cause for ascites formation (such as malignancy or tuberculosis). Thus, a high SAAG is indicative of portal hypertension but does not exclude concomitant malignancy.
In Western societies, half of patients have underlying cirrhosis and ascites from portal hypertension. In such patients, a diagnosis of tuberculous peritonitis may go unsuspected because symptoms are attributed to the underlying liver disease. A high index of suspicion is required for prompt diagnosis and treatment.http://www.sma.org/smj1999/aprsmj99/ahmad.pdf

A LBW infant at 2 months of age is brought because he has not benn eating well. On P/E, he’s pale & tacchycardic, The lungs are clear and there’s no hepatosplenomegaly. CBC shows Hgb= 6 mg/dl, which of the ffg is the most likely cause of anemia in this infant?
a- Megaloblastic
b- Sickle cell dis.
c- Anemia of prematurity
d- Alfa thalassemia
e- Homozygous beta thalassemia

Answer is c- anemia of prematurity, which occurs in LBW infants 1-3 months after birth. Hgb is below 7-10 gr/dl.

You are called to see a 29 y/o woman, who was admitted to the hospital 24 hrs earlier because of a stiff neck and a temperature of 39.7 C (103.4 F). She is presumed to have meningitis, but the results of the CSF analysis are still pending. An LP was performed when she arrived at the hospital and IV antibiotics were started. She is now complaining of a dull, frontal headache that is worse when she is sitting upright and relieved by lying down. V/S: T=39.3 C (102.8 F), BP=110/70, PR= 75/min, RR=18/min. P/E shows nuchal rigidity and there is a palpable purpuric rash on her lower extremities and trunk. Funduscopic examination is unremarkable. The most appropriate next step is to
A. administer sumatriptan, intramuscularly
B. advise her to remain in a horizontal position
C. ask her if she has been drinking red wine
D. order a CT scan of the brain to look for intracranial hemorrhage
E. order an MRI of the brain to look for an intracranial mass
The correct answer is B. advise her to remain in a horizontal position
This patient most likely has a LP headache, which often begins within 24 hours of the procedure. The headache is positional in nature, meaning that it is worse when she is sitting upright and relieved by lying down. It is believed to be due to a loss of cerebrospinal fluid during the lumbar puncture, causing decreases in the cushioning of the brain. Patients should be told to remain horizontal after the procedure to decrease the incidence of this complication. The treatment includes remaining in a horizontal position and possibly intravenous caffeine sodium benzoate. If this is not effective, an epidural blood patch should be performed.

A 28 y/o man comes to the ED because of moderate Lt. shoulder pain that is worse with abduction of the shoulder. He plays baseball occasionally with friends and has noticed that the pain worsens when throwing the ball. He denies any Hx of trauma. On P/E weakness of the shoulder, most pronounced with abduction is noted. A shoulder x-ray reveals no fractures or dislocations. The most appropriate next step in management is to
A. advise patient that he should rest and ice the shoulder
B. order an emergent CT scan of the shoulder
C. order an emergent MRI of the shoulder
D. order an outpatient MRI of the shoulder
E. prescribe nonsteroidal antiinflammatory drugs
The correct answer is D. order an outpatient MRI of the shoulder
Rotator cuff tears are chronic use injuries most common in throwing athletes. The clinical symptoms are weakness and instability of the shoulder. An x-ray may show a subacromial spurring, a high-riding shoulder, or calcific tendonitis. Diagnosis is made by MRI of the shoulder. This is a non-emergent diagnosis and the imaging can be performed on an outpatient basis. Repair is made arthroscopically.

A 17 y/o girl comes to the clinic because of a "reddish bump" on her abdomen. She states that she has had it for as long as she can remember, but her current boyfriend is concerned that it may be "cancer". She has no other complaints and does not take any medications other than ocp for birth control. Her grandfather has malignant melanoma of the eye and her mother has breast cancer. P/E shows a 0.4cm pinkish-brown, raised lesion on the left periumbilical region, 3cm lateral to the umbilicus. A small amount of soft tissue is palpated beneath the lesion. It is directly on an imaginary line that you can trace along the body from the left axilla to the left inguinal region. The remainder of the physical examination is normal. In discussing this lesion with the patient, you should inform her that :
A. coal tar ointment and ultraviolet light therapy is an old but useful treatment
B. she has a 70% chance of having a kidney and/or urinary tract defect
C. the lesion needs to be removed immediately because it is precancerous
D. this is most likely a congenital defect that can be removed for cosmetic purposes
E. this needs to be removed immediately and she will need radiation therapy
The correct answer is D. This patient most likely has an accessory nipple (polythelia) and extraglandular breast tissue (polymastia), which are present in approximately 2% to 5% of the population. They usually occur along the "milk line," which is an embryologic line that extends from the axilla to the inguinal region. Normal breasts form along this line and other areas of breast tissue and accessory nipples can too. Patients often think that they are "moles" and generally are only concerned about the cosmetic appearance. They can be simply removed as an outpatient, and additional treatment is not usually necessary.

A 74 y/o woman comes to the ED because of a 5 hr history of Rt sided weakness. The sudden weakness came on while she was giving her husband a bath. She says that she was sure that she was having a stroke because her husband has had 2 strokes in the past, but her symptoms resolved spontaneously before she arrived at the hospital. She is very concerned about her risk for a stroke because her husband is completely dependent upon her for care. She is able to ambulate normally and has no residual functional loss. BP=110/80 mm Hg, PR=70/min. Funduscopic examination is normal. A thorough neurologic examination is unremarkable. The most appropriate next step is to :
A. advise her to take a daily aspirin
B. auscultate the carotid arteries
C. obtain an MRI of the head
D. order a carotid sonogram with Doppler
E. schedule an elective carotid endarterectomy
The correct answer is B. This patient most likely had a transient ischemic attack, which is a neurologic event that lasts for less than 24 hours. It is often due to atherosclerotic disease and therefore auscultation of the carotid arteries may demonstrate the presence of a bruit, which suggests atherosclerotic disease at the carotid bifurcation. TIAs from carotid disease may occur due to ischemia from stenosis or from an embolization of small plaques from the ulceration of the plaque. The next step in this case is to auscultate the carotid arteries because this is the least invasive, cheapest, and quickest method to detect atherosclerotic disease.

A 92 y/o man is brought to the clinic by his son and daughter who tell you that their father "has gone blind". Further investigation uncovers that his visual loss has been a slowly progressive process with no ocular pain. His son and daughter are concerned because the patient lives alone. The patient does not complain of any difficulty seeing and is agitated that he has been brought to your office. Examination reveals normal vital signs and a visual acuity of 20/400 in both eyes. Pupil examination, extraocular movements, and confrontational visual fields are all normal. A penlight exam of the eye shows a yellow-brown color to the lens in both eyes, but is otherwise unremarkable. Direct ophthalmoscopy is very difficult and a sharp view of the retina is not possible. The family should be advised that:
A. Age alone is a common cause of decreased vision and his level of vision is what you would expect for a patient his age
B. Eye surgery is necessary to prevent total blindness (no light perception)
C. Glaucoma is the most likely diagnosis and prompt ophthalmology consult is indicated
D. He has macular degeneration and low vision aides should be considered to assist with activities of daily living
E. Tell the patient and family that as long as the patient is comfortable with his vision no treatment is necessary
The correct answer is E. This patient has cataracts in both eyes. The typical clinical presentation of a patient with cataracts is that of slowly progressive visual loss. Patients may also complain of difficulty with glare and bright lights. They often note decreased color brightness and contrast sensitivity. On exam, a lens that has a cataract will appear yellow-green to yellow-brown. A mature cataract will present as a white lens and visual acuity of hand motions or light perception. With advanced cataracts, the fundoscopic exam may be difficult or not possible. The treatment for cataracts depends on the level of visual deficit experienced by the patient. Appropriate treatments range from observation/education, spectacles, and cataract surgery. If a patient with cataracts is comfortable with his current vision, then treatment with glasses or surgery is not necessary. Referral to an ophthalmologist may be appropriate for more in depth counseling based on the level of concern of the patient.

A 3 y/o boy is brought to the ED by his parents because of a 24 hr Hx of intermittent, generalized abdominal pain. The parents tell you that he complains of the pain for 10-minute episodes and during these times he refuses to walk, but then he spontaneously returns to his normal activities. This occurred 8-9 times yesterday. Today the symptoms occurred more frequently and were associated with 3 episodes of non-bloody, non-billous emesis so the parents brought him into the hospital. There is no history of fever, constipation, or soiling. On examination the patient appears tired and has mild diffuse abdominal pain. He has guaiac-positive stool. PR=125/min. The study most likely to provide a diagnosis is :
A. an abdominal x-ray
B. a barium enema
C. a CBC with differential
D. a CT scan of the abdomen
E. a LP

The correct answer is B. This patient presents with a very common complaint in the pediatric population, abdominal pain. The key to this case is the quality and frequency of this abdominal pain. The pain was described as being diffuse and intermittent with periods of resolution of the symptoms. This type of pain pattern, along with emesis, the lethargy seen in the emergency department, and the guaiac-positive stools should raise red flags for the diagnosis of intussusception. In intussusception a segment of bowel (most commonly the distal ileum into the cecum) telescopes into an adjacent segment causing obstruction. This obstruction tends to resolve and recur causing the intermittent abdominal pain. The barium enema is diagnostic and in many cases a curative procedure as well and is therefore the study of choice in this case.

A 64 y/o farmer comes to the clinic with an injury to the foot, which happened at his farm 24 hrs ago. He reports that he was working on the farm, when he accidentally stepped on a rusty nail, which penetrated deep into his foot. He took some analgesics and he was feeling well. His wife urged him to come to the clinic. He denies any fever, chills, or rigor. His past medical history is significant for non-insulin dependent diabetes mellitus, which is well controlled with oral therapy. He has no past surgical history. Examination of the foot reveals a deep penetrating wound in the sole of the left foot. There is no associated erythema or induration around the foot. No foreign particles are noted along the edges of the foot, which is tender on palpation. There is no motor or sensory loss. No active bleeding is noted in the penetrating wound. The patient tells you that he had 3 doses of tetanus toxoid injections when he was young. The last tetanus injection was 8 years ago for a similar episode. The most appropriate next step in management is to
A. administer a tetanus toxoid booster injection
B. administer a tetanus toxoid booster injection and human immunoglobulin
C. provide human immunoglobulin
D. provide no additional therapy at this time
E. surgically debride the wound
The correct answer is A. Tetanus prone wounds are any wounds that are over 6 hours old, deep, crushed or penetrated, contaminated with soil, associated with compound fractures, partial or full thickness burns, or human or animal bites. Patients who received 3 doses of tetanus toxoid in the last 5 years do not need further therapy for a tetanus prone wound or for a clean wound. Patients who received a tetanus toxoid between 5-10 years ago and have a tetanus prone wound need booster tetanus toxoid injections, whereas those with a clean wound would need no further therapy. When the last dose of tetanus toxoid was more than 10 years ago, then both clean wounds and tetanus prone wounds need tetanus toxoid booster injections. In addition, those with a tetanus prone wound, whose last dose was more than 10 years ago, need to have human immunoglobulin (choice C) administered.

** A 60 y/o diabetic male is brought to ER by his wife for evaluation. His wife reports that he had developed high fevers 2 days prior, which were attributed to a viral infection and no medical attention was sought. His wife became concerned when the fever persisted despite the use of Tylenol and he became increasingly lethargic.
Vitals: HR=130, RR=24, BP=70/55, T=102F
On examination, he was flushed, warm to the touch, confused, and diaphoretic. Mucus membranes appeared dry. His neck was supple with negative Kernig and Brudzinski signs. His eyes were equal and reactive to light with no papilledema, and his lungs were clear to asculation bilaterally with no evidence of rales, rhonchi, or wheezes. On cardiac exam he was tachycardic with a normal S1 and S2. A flow murmur was heard. The abdominal and neurologic exams were unremarkable. Examination of the dorsal aspect of the right foot revealed foot cellulites. What would be the first appropriate step of treatment in this man?
A. Immediate dose of IV cefazolin (Ancef)
B. Fluid resuscitation with normal saline
C. Drainage and culture of wound site
D. Obtain CBC, Chem 10, ABG, blood cultures, urine cultures, wound culture
E. Stat CT of head

Answer is B.
This patient is in septic shock given his BP of 70/55 and temperature of 102F. In addition, patient demonstrates flushing, which indicates vasodilation, another characteristic of septic shock. This is most likely the result of bacteremia secondary to his foot cellulitis. In hemodynamically unstable patients, airway, breathing, circulation should be assessed and fluid resuscitation should be started immediately. This should be quickly followed by drainage and culture of wound site, urine culture, and bloodwork including: CBC, Chem10, ABG, blood cultures. Furthermore, empiric antibiotics should be started intravenously. In this case, the most common organisms would be Strepococcus and Staphylococcus, making cefazolin (Ancef) would be an appropriate choice.
Mental status changes are often evaluated by CT scan. However, this patient's changes are most likely secondary to his hemodynamic instability and should resolve with resolution of his septic shock.

** A 25 y/o female is brought to ER after being involved in a MVA. She is hypotensive and tachycardic. She has good breath sounds bilaterally. Fluid resuscitation is started immediately with Lactated Ringers solution, and blood is sent for type and cross. She has minor scrapes and lacerations on her torso. She remains hypotensive even after 2L of Lactated Ringers solution and blood transfusion with packed red blood cells is begun. After infusion of 2 units, her blood pressure stabilizes at 110/80 mm Hg. She is placed under observation. 3 hours later she complains of chills, generalized pruritus and difficulty breathing. On exam she is found to have a temperature of 101 F, BP of 110/80, HR 100, RR 20. HEENT is normal. Neck is supple with no JVD. Auscultation of the lungs reveals crackles at the bases. Heart exam is normal. Abdomen is soft, nontender, nondistended, with good bowel sounds, there is no hepatosplenomegaly. Extremities reveal no edema, no cyanosis, and good range of motion. Neurologic exam is unremarkable. Examination of skin reveals a generalized urticarial rash. She is treated with diphenhydramine (Benadryl) and acetaminophen with resolution of symptoms.
In the future, if this patient were to require another blood transfusion, what precautions need to be taken?
A. None
B. Only leukocyte poor packed red blood cells should be given.
C. Only irradiated packed red blood cells should be given.
D. Only CMV negative packed red blood cells should be given.
E. This patient is not a candidate for any further blood transfusions.

Answer is B.
Patient is experiencing a leukoagglutinin reaction. This is an immunologic reaction to antigens present on the white blood cells which are invariably present in the transfused blood products. It occurs most commonly in patients who have been sensitized through previous transfusions or pregnancies. Typical presentation includes fever and chills within 12 hours after transfusion. In addition, cough and dyspnea often occur. Patients respond to acetaminophen and benadryl. Depletion of white blood cells from the blood products can reduce the incidence of future reactions. Pretreatment with acetaminophen and benadryl may also help reduce the recurrence of the reaction.

** A 35 y/o African American female presents to her primary care physician complaining of pain in both legs. The pain started one day ago and got progressively worse. It is localized mostly on the anterior aspect of her legs below the knees. She also complains of malaise and fatigue and thinks she may have a low grade fever. She has no significant past medical or family histories. She takes no medications and is not allergic to any medications. She denies alcohol, tobacco or recreational drug use.
Physical exam is unremarkable except for tender erythematous nodules located on the extensor surfaces of both legs below the knees.
A chest Xray is done,which demonstrates hilar lymphadenopathy with no parenchymal involvement. What’s the most likely Dx?
Answer is sarcoidosis.
Painful red nodules located on the anterior aspect of the legs is typical of erythema nodosum. Erythema nodosum may be associated with various infections such asTB, coccidiomycosis, streptococcosis, hepatitis B, syphilis, and yersinia. It may also be due to drugs such as sulfonamides and ocp. Other diseases that are associated with it include sarcoidosis, rheumatic fever, leukemia, and IBD.
The erythema nodosum in this patient is most likely secondary to sarcoidosis as evidenced by the significant hilar lymphadenopathy. In addition, the incidence of sarcoidosis is highest in African Americans, and women are affected much more frequently than men. Disease onset is commonly in the third or fourth decade of life.

*** A 43 y/o homeless man is brought in by the paramedics after he was found confused and wandering in the streets. On evaluation he is agitated, confused and combative. He is diaphoretic, emanates a foul odor, and his clothes are filthy with evidence of emesis. He has slurred speech, is noted to be talking to people who are not there, and swatting at invisible objects. Upon questioning he makes an incoherent comment about seeing bugs on the walls. He has a generalized tremor and appears fearful of the staff. His vital signs show: BP 135/80, HR 102, RR 20, Temp 99.8 F. His mucus membranes are dry and skin turgor is normal. Chest and cardiac exams are normal. Abdominal exam is significant for slight hepatomegaly. Neurologic exam reveals intact cranial nerves, DTR's are symmetric bilaterally, but he refuses to cooperate with the remainder of the neurologic exam. He is disoriented to person, time and place.
Which of the following changes are consistent with this patient's presentation?
AST ALT MCV [Mg+2] Glucose
A. inc No change No change dec dec
B. inc inc inc dec dec
C. inc inc No change inc dec
D. No change inc No change inc inc
E. No change No change inc No change inc

Answer is B.
This patient is exhibiting signs and symptoms of delirium tremens (DT). DT is organic psychosis, which is usually the result of acute alcoholic withdrawal. It is characterized by mental confusion, tremors, visual hallucinations, diaphoresis, and autonomic hyperactivity. It usually manifests within 25-72 hours after the last drink, but, can occur as late as 7-10 days later. DT tends to occur in individuals with previous withdrawal episodes.
This patient is a chronic alcoholic and alcohol can cause liver damage. As a result he can be expected to have elevated AST and ALT levels. Usually AST is two times more elevated than ALT. Gluconeogenesis in the liver may be impaired resulting in hypoglycemia. In addition, hypoglycemia, hypomagnesemia and an elevated MCV are commonly seen in alcoholics, and are most likely the result of malnutrition.

** A 19 y/o college student with height 5'2" and weight 120lbs is brought to the emergency room after she experienced two episodes of coffee ground emesis. Her vital signs on arrival are normal. On physical exam she has poor eye contact and a blunted affect. She is oriented to person, time and place. Her mucus membranes are moist, front teeth show loss of enamel. She has mildly enlarged parotid glands bilaterally. Her breath has a rancid odor. Her chest and cardiac exam are normal. She has mild epigastric tenderness, good bowel sounds, no distention, no hepatosplenomegaly. Neurologic exam is unremarkable. A nasogastric tube is placed which drains clear fluid after an initial 10ccs of coffee ground material. An upper endoscopy is performed which demonstrates a linear mucosal tear at the gastroesophageal junction and a diagnosis of a Mallory-Weiss tear is made.
From your understanding of the patient's underlying condition, which of the following acid-base abnormalities would you expect?
A. Hypochloremic metabolic alkalosis
B. Hypochloremic metabolic acidosis
C. Hyperchloremic metabolic alkalosis
D. Hyperchloremic metabolic acidosis
E. No abnormalities are expected.

Answer is A
On Hx & P/E , this patient has many concerning signs and symptoms. Her worn-appearing enamel, bilaterally enlarged parotid glands, rancid breath odor, and poor eye contact point to an eating disorder, most likely bulimia nervosa, given her normal height to weight ratio. In addition to her chronic disease, she is acutely experiencing pain secondary to a Mallory-Weiss tear. A Mallory-Weiss tear ia a mucosal tear at the gastroesophageal junction, which arises from events that suddenly raise transabdominal pressure. Examples include sudden lifting, or as in this patient, retching or vomiting. Given this patient's history of retching and vomiting, one would expect her to have hypochloremic metabolic alkalosis, as H+ and Cl- are lost during vomiting.

Answer is d- quinidine.
Quinidine slowers the atrial rate due to it’s vagolytic action & increases AV conduction. So, an atrial flutter at 200/min was conducted to the ventricles in a 1:1 ratio, resulting in an increase in ventricular rate to 200/min. This effect could be avoided by use of a drug that slows AV nodal conduction like choices a, b, c & e.

35 y/o woman, G3P2, at 39 wks gestation undergoes a vaginal delivery of a 3295 gr male neonate. The placenta was not completely removed & after bleeding she underwent a total abdominal hysterectomy due to placenta accreta & receives 5 unites of packed RBC. Which of the ffg hormones are most likely to be affected by this scenario?
a- ACTH
b- PRL
c- TSH
d- FSH
e- ADH
f- None of the above
g- All the above

Answer is b- PRL due to developing sheehan’s syn.

A 26 y/o woman with recently diagnosed Hodgkin's disease is admitted to the ICU after an overdose of lorazepam and alcohol. She is intubated and stable. Which of the ffg would be expected to help prevent the development of ventilator-associated pneumonia in this patient?
A. Keeping the patient in the semi-recumbent position
B. Routine changes of the ventilator circuit
C. Nasotracheal (as opposed to oral) intubation
D. Prophylactic antibiotics
E. Chest physiotherapy
Answer is A. Keeping the patient in the semi-recumbent position
Ventilator-associated pneumonia accounts for more than 50% of all infections in the ICU. Handwashing, semi-recumbent positioning, kinetic (rotational) bed therapy, and drainage of condensate from ventilator circuits are effective strategies for preventing such infections. However, routine changes of the ventilator circuit and chest physiotherapy are ineffective. There is some evidence to support oral, as opposed to nasal, intubation. Influenza and pneumococcal vaccination, which should be addressed in all patients at the time of hospital discharge, would not affect the development of ventilator-associated pneumonia.

In a patient with steatorrhea, which of the following test results is the most specific for the diagnosis of chronic pancreatitis?
A. Abnormal Schilling test that does not normalize with intrinsic factor
B. A serum carotene value of 25 µg/mL
C. A 72-hour fecal fat content of 30 g
D. A serum trypsinogen value of 5 ng/mL
E. An abnormal 13C triolein breath test
Answer is D. a serum trypsinogen of 5 ng/ml
The serum trypsinogen concentration, when low, is the only test in this group that is specific for pancreatogenous steatorrhea. The other test results are associated with, or diagnostic of, steatorrhea but do not identify specific cause of steatorrhea.
The Schilling test, if abnormal after intrinsic factor, can occur with ileal disease, bacterial overgrowth, or chronic pancreatitis. A low serum carotene concentration, abnormal 72-hour fecal fat test, or abnormal 13C triolein breath test are present with steatorrhea of any cause, for example, small bowel mucosal disease, bacterial overgrowth, chronic pancreatitis, and ileal resection.

A 38 y/o farmer has acute onset of severe, progressive dyspnea associated with cough and weakness. These symptoms occurred 1 hour after the patient had worked in a silo that had been filled with fresh corn silage the previous day. Which of the following is most likely to have caused his acute pulmonary decompensation?
A. Exposure to thermophilic actinomyces
B. Viral pneumonia
C. Pneumothorax
D. Nitrogen dioxide pneumonitis
E. Allergic bronchopulmonary aspergillosis
Answer is D. Nitrogen dioxide pneumonitis
Silo filler's disease results from inhalation of oxides of nitrogen, including nitrogen dioxide, which tends to accumulate at the top of tall storage silos. The oxides of nitrogen are generated soon after the silo is filled with fresh silage that is subsequently used for animal feed. Nitrogen dioxide, when dissolved in the aqueous film that lines the respiratory tract, becomes nitric acid and produces a chemical pneumonitis. When the farmer enters the top of the silo to level the silage or prepare it for mechanical unloading, exposures can be quite high. The chemical pneumonitis of silo filler's disease must be differentiated from farmer's lung, which is an immunologic reaction to molds or thermophilic actinomycetes that grow in hay during the storage season. Exposure to this organic material occurs when farmers spread the hay for animal feed during the winter. Hypersensitivity pneumonitis can then occur 6 to 8 hours after exposure.

a 2 y/o symptomatic HIV-infected child presents because of exposure to measles. His immunization is up to date. He received IG 6 wks ago, which of the ffg is the most appropriate course of action?
a- Administer monovalent measles vaccine
b- Administer another MMR vaccine
c- Administer IG
d- Administer Vit C
e- Do nothing, because the child is already immunized for measles
Answer is c- Administer IG.
Symptomatic HIV infected children exposed to measles should receive IG prophylaxis regardless of vaccination status, because they have poor immunologic response to vaccine. If a child received IG within 3wks of exposure , no additional IG is required.

A 27 y/o woman with schizophrenia and hx of seizure is stabilized on valproate & then started on clozapine. One wk later, she complains of sedation & sialorrhea. Which of the ffg should be performed immediately?
a- clozapine level
b- prolactine level
c- thyroid function
d- valproate level
e- WBC count
Answer is e- WBC count.
Weekly monitoring of WBC count during Tx with clozapine is required because 1% risk of agranulocytosis. Sedation & sialorrhea are untoward effects of clozapine Tx. Clozapine & valproate level may have clinical significance, but are not immediately required.

A 7l y/o woman presents with pain in the Rt. lateral thigh and buttock. She has had this pain for the last 6 months, and symptoms are aggravated by prolonged standing and walking, and they improve with rest. In recent years, she has also had intermittent LBP, but there has been none in the last 6 months.On P/E, the patient has mild limitation of rotation in both hips but no pain on motion. There is diffuse mild tenderness in the Rt. lateral thigh and buttock. Abduction of the hips against resistance does not increase her pain. The lumbar region of the spine is not tender, but there is moderate increase in lumbar lordosis and in paravertebral muscle tone. Her pain is not increased by bending forward, but there is some increase in pain with full spinal extension. There are no neurologic deficits.What is the most likely cause of this patient's pain?
A. Osteoarthritis of hip
B. Arthritis of sacroiliac joint
C. Trochanteric bursitis
D. Osteoarthritis of lumbar spine
E. Spinal stenosis
Answer is D. Osteoarthritis of lumbar spine.
Referred pain from the lower lumbar facet joints or intervertebral discs is often reported by the patient as hip pain, with localization to the buttock and lateral thigh. The pain is characteristically aggravated by maneuvers that increase the force brought to bear on these joints, particularly spine extension as well as lateral bending or rotation toward the painful side. Pain over the spine may or may not be present, but even in its absence, there may be paravertebral muscle spasm contributing to reduced spine motion. Frequently referred pain may have a different localization from radicular pain at the same level. Lower lumbar nerve root impingement usually causes pain below the knee.
Pain resulting from hip joint pathology is usually felt in the groin and anterior thigh. Hip motion, particularly rotation, is usually painful. Sacroiliac arthritis usually results in constant pain and is particularly severe in the morning and improves with motion. Trochanteric bursitis causes lateral hip and thigh pain, with tenderness over the trochanter. A provocative test designed to increase the pain involves abduction of the hips against resistance; this results in contraction of muscles that attach to the trochanter. The maneuver did not increase pain in this patient. Spinal stenosis causes compression of lumbosacral nerve roots, usually producing bilateral lower leg pain.

A 60 y/o woman has a long hx of subumbilical abdominal pain occurring during periods of stress and sometimes aggravated by ingesting coffee, nuts, or chocolate and by constipation. Recently, the pain has become worse on the left side of the abdomen. The results of barium enema and upper GI series are normal, and a CT of the abdomen and pelvis shows a 3 x 3-cm loculated cyst in the tail of the pancreas. There are no cysts in the liver or kidneys. The results of all blood tests, including the test for amylase, are normal. The best management of this patient is:
(A) Surgical removal of the cyst
(B) Three monthly CT scans to determine whether the cyst enlarges or subsides
(C) Reassurance and no further evaluation
(D) ERCP to determine whether the cyst communicates with the pancreatic duct
(E) Needle aspiration of the cyst and examination of the cyst fluid

Answer is A.
The incidental finding of a pancreatic cyst can be a difficult decision-making problem. In the healthy patient, the best course is to advise surgery. It is almost impossible to distinguish a cystadenoma from a cystic adenocarcinoma or a benign solitary cyst due to chronic pancreatitis from a malignant cyst or mucinous duct ectasia. Because about 20% of these cysts turn out to be malignant, the patient may prefer to opt for one of the other alternatives, for example, three monthly CT scans to determine whether the cyst enlarges, ERCP to determine whether the cyst communicates with the pancreatic duct and this is more likely to be due to pancreatitis, or a needle aspiration of the cyst and examination of the cyst fluid for malignant cells. Clearly, in older patients with multiple medical problems, one might agree to this course before undertaking surgery. However, whatever course is decided upon one should be very wary of telling the patient that they have a small insignificant finding and nothing further needs to be done.

Abdominal ultrasound demonstrates massive ascites, a small diffusely echogenic liver without focal masses or biliary dilation, and splenomegaly.
The most appropriate treatment at this time is:
(A) Addition of hydrochlorothiazide therapy
(B) Total paracentesis with albumin infusion (6 to 8 g/L of fluid removed).
(C) Continue current diuretic therapy and re-educate the patient about dietary salt restriction
(D) Discontinue diuretic therapy and observe
Answer is D.
This patient has decompensated liver disease, has developed tense ascites despite aggressive diuretic therapy with high doses of combined diuretic therapy, and presents with hyponatremia and renal insufficiency. His ascites can be considered diuretic-intolerant because he demonstrates hyponatremia and renal insufficiency on the current regimen. Consequently, continuing the present diuretic regimen is not appropriate; his condition would likely deteriorate further if more aggressive diuretic management with addition of thiazide diuretics were attempted.
Large-volume or total paracentesis is effective in managing refractory ascites. It is recommended that this be performed with albumin infusion (6-8 g/L) to decrease the risk for exacerbation of renal insufficiency. It has been shown that large-volume paracentesis (5 L) can occasionally result in prolonged circulatory dysfunction typified by decreased intravascular volume in cirrhotic patients when performed without colloid infusions. In this patient with marked renal insufficiency, as suggested by a serum creatinine of 1.9 mg/dL in the setting of advanced liver disease and muscle wasting, who has no symptoms attributable to large-volume ascites that necessitate immediate treatment, large-volume paracentesis may result in deterioration despite colloid infusion and should be avoided. Consequently, this patient can be considered diuretic intolerant; discontinuing diuretics and observation is the preferred therapy at this time.

Which of the following can cross the placental membrane ?

a. IgM
b. Insuline
c. Bacteria
d. Methyl Dopa
e. Steroid Hormones

answer is e.

68 y/o man is brought to you in a comatose state, his eyes are in midposition and pupils are pinpoint, what is the most likely location of the hemorrhage?
a. pons
b. putamen
c. thalamus
d. cerebellum
The correct answer is a. pons.
Option b is incorrect, putament hemorrhage cause deviation of both eyes to the side of the lesion (away from hemiparesis), but the sizes of pupils are normal. Option c is also incorrect, in thalamus hemorrhage, although the sizes of the pupils are small; both eyes are deviated inward and look at nose. Option d is also incorrect, patients with cerebellum hemorrhage have a normal size of pupils and they are unable to look toward the side of the lesion.

23 y/o woman presents with excessive hair growth on face, chest, and on the abdomen, her physical and blood examinations are normal, what is the most likely cause?
a. familial
b. ovarian tumor
c. 21-hydroxylase deficiency
d. polycystic ovary syndrome
The answer a. Familial (or idiopathic) is the most common cause of hirsutism. Ovarian tumors are very rare causes of hirsutism (only 0.8%). 21-hydroxylase deficiency causes ambiguous genitalia in baby girls. Polycystic ovary syndrome is suspected in obese women with amenorrhea and a serum LH:FSH ratio greater than 2.0.

A 35 y/o African American man presents to your office for a first time visit. He has no past medical history, and takes a multivitamin daily. He is active and runs approximately 3 miles/wk. He has a 10-pack/yr Hxof smoking and has 1-2 beers/wk.
v/s: T=37 C (98.4 F), BP=110/60 mm/Hg, PR=65/min and regular, and RR=15/min. On P/E, a II/VI systolic ejection murmur at the Rt. upper sternal border is noted that has no respiratory variation, increases in intensity upon going from supine to standing and Valsalva, and decreases in intensity with sustained handgrip. There is a prominent, nondisplaced PMI. The remainder of his examination is unremarkable. The most likely Dx is:
A. aortic stenosis
B. IHSS
C. MR
D. PDA
E. tricuspid regurgitation

The correct answer is B. IHSS
This condition involves an aortic outflow obstruction that is dependent upon both preload and afterload. As preload is decreased (i.e., as with a Valsalva maneuver or moving from supine to erect) the ventricular chamber size is decreased, the degree of outflow obstruction is increased, and the intensity of the murmur is increased. As the afterload is increased (i.e., with handgrip) the end systolic chamber size is increased, the degree of outflow obstruction decreased, and the intensity of the murmur is decreased. The prominent PMI suggests a left ventricle that has hypertrophied in response to the outflow obstruction. The identification of IHSS is important since those with this form of cardiomyopathy are at increased risk for sudden death.

A 57 y/o man with schizoaffective disorder, whose symptoms were in remission until 2 wks ago, is brought to the ED by his girlfriend. He will not talk with you but the girlfriend tells you that he has a hx of "overdoses", and she is afraid he has taken a lot of "his pills". He has been complaining of voices telling him he "should be dead". He has not left the house in a month and has spent several hours a day looking out the window for the "king and savior" to "come take him". His medications include haloperidol, valproic acid, and a small dose of amitriptyline for chronic pain related to nerve damage in his leg, which occurred in a motor vehicle accident 10 years ago. He has no other medical problems. A chart review reveals that he has no allergies and was diagnosed with schizoaffective disorder 30 years ago.
Vitals: T=37.0 C (98.6 F), BP=110/70 mm Hg, PR=70/min, and RR=26/min. He is a depressed appearing man with very poor eye contact. He smells of alcohol. He does not acknowledge you, but will answer some questions for his girlfriend. He does admit to feeling that "life is not worth living" and feeling "more religious than usual". He seems slightly drowsy and knows the date. His physical examination is normal. The most appropriate next step in management is to order
A. acetaminophen and salicylate levels
B. blood alcohol level
C. ECG
D. urine toxicology for street drugs
E. valproic acid level

The correct answer is C.ECG
This patient may have taken several cardiotoxic medications. Haloperidol and other antipsychotics increase the QT interval, as do the tricyclics. In an overdose for either medication, he is at risk for sudden death from torsades.

A 14 y/o boy is brought to the office by his mother because of "bedwetting" episodes that have been occurring about twice a week for the past few months. The mother says that she noticed this "problem" when she washed his pajamas, and he "refused" to talk about it when she tried to bring it up. She is hoping that he will talk to you. You ask her to leave the room so you can have some privacy with her son. He starts the conversation by stating that "this is getting embarrassing" and he "doesn't understand what's going on." He says that he gets up and finds his pajamas "wet and sticky." He denies any dysuria or frequency during the day, and denies any problems at school or at home. He is on the basketball team, socializes with friends, and gets good grades. Physical examination is unremarkable and shows a pubic hair stage of Tanner IV and genital development Tanner stage III. The next best step is to
A. advise him to stop drinking water at 8 pm and urinate before bed
B. begin a 3-day treatment regimen with trimethoprim-sulfamethoxazole
C. obtain a urine sample for U/A & culture and sensitivity
D. order a renal ultrasound
E. reassure him that this is a completely normal part of puberty
F. order CBC & electrolytes

The correct answer is E. reassure him that this is a completely normal part of puberty
This adolescent boy is most likely having nocturnal emissions ("wet dreams"), which are a normal part of puberty. A nocturnal emission is when the penis becomes erect during sleep and ejaculates. If the boy or his mother do not know about nocturnal emissions before they occur, they may think that he urinated. He should be reassured that this is normal. It is also important to discuss it with his mother so she does not make him feel uncomfortable about it in the future.

A 36 y/o woman comes to the ED because of a severe headache. She states that the headache woke her up from sleep 6 hours ago, and was not relieved by aspirin or acetaminophen. She also noticed that she has neck stiffness and that "it hurts" during neck extension and flexion. She was recently diagnosed with Hodgkin's disease, but before that, she was usually "pretty healthy," except for a few UTI and HTN. V/S: T=39.0 C (102.2 F), BP=130/80 mm Hg, PR=75/min, and RR=17/min. She appears lethargic. P/E shows nuchal rigidity, flank tenderness, and a mid-systolic click. Funduscopic examination shows bilateral optic disc swelling. What’s the most appropriate first step to do:
A. B/C & administer IV ceftriaxone
B. order a CT scan of the head
C. order a MR angiogram of the head
D. order an MRI of the head
E. perform a LP

The correct answer is A. B/C& IV ceftriaxone
This patient has the signs and symptoms that are suggestive of meningitis, but she also has papilledema (optic disc swelling), which means that an intracranial mass must be ruled out before performing a lumbar puncture (to reduce the risk for brain herniation). However, empiric antimicrobial therapy should be started before the neuroimaging study so that clinical deterioration does not occur.

A 17 y/o girl is brought to the office by her mother because she has missed “many periods”. The girl admits to binge eating and exercising in order to prevent weight gain. She tells you that she is definitely not pregnant, because she has not had any sexual relations in the past 11 months and thinks she is not getting her menstrual period because of the excessive physical exercise she has been doing in the past several weeks. P/E is significant for bradycardia and significant weight loss compared to the last year. A pregnancy test is negative.At this time what’s the first step?
A. order amylase
B. check BUN and creatinine
C. order LFT
D. check serum K
E. thyroid function tests

The correct answer is D. check serum K
Bulimic patients frequently engage in compensatory behaviors to prevent weight gain. Those include self-induced vomiting, abuse of diuretics, laxatives, enemas, or diet pills. The metabolic disorders frequently seen in these patients are, mostly hypokalemia and hypomagnesemia. Thyroid function tests should be done as a part of regular workup of patients presenting with this clinical picture. It is not, however, the first to be ordered.

answer is d- hormonal manipulation
this elderly px has metastatic prostate cancer, so Mx would be tumor control for palliation of symptoms, which is hormonal manipulation either with orchiectomy or exogenous estrogen therapy.

A 75 y/o woman is brought to ER from nursing home for jaundice & mental confusion. The nusrsing home notes states that she became less responsive & developed jaundice over the last 2 wks. PMH is positive for HTN, DM & prior colon resection for colon cancer at age 55. V/S : BP= 100/60, HR= 110, T= 101.5, P/E shows no response to verbal command but withdraws to pain, a mild jaundice with tenderness in epigastrium & RUQ. What’s the most likely Dx?
a- Hepatitis A
b- Biliary stricture
c- Choledochal cyst
d- Liver metastasis
e- Choledocholithiasis
f- Cirrhosis
g- Pancreatitis

Answer is e- choledocholithiasis.
Common bile duct stones may be the cause of acute bile duct obstruction without warning resulting in jaundice, pain & sepsis. The sepis may manifest as fever, hypotestion & altered mental status.

A 66 y/o woman who has previously been healthy undergoes emergency surgery for a ruptured AAA. Intraoperatively she requires 8 units of packed red blood cells to maintain her blood pressure and hematocrit. After surgery she is hemodynamically stable. On the third post-op day she appears jaundiced, but abdominal examination is unremarkable and she is afebrile. Lab results:
Total serum BR=8.3 mg/dL (direct= 6.3 mg/dL)
Serum Alk. Ph.= 360 U/L
Serum AST = 51 U/mL
The most likely explanation for the woman's jaundice is
A: a stone in the common bile duct
B: halothane hepatitis
C: posttransfusion hepatitis
D: acute hepatic infarct
E: benign intrahepatic cholestasis

The answer is E- Benign intrahepatic cholestasis
Benign post-op intrahepatic cholestasis can develop as a consequence of major surgery for a catastrophic event in which hypotension, extensive blood loss into tissues, and massive blood replacement are notable. Factors contributing to jaundice include the pigment load from transfusions, decreased liver function resulting from hypotension, and decreased renal bilirubin excretion caused by tubular necrosis. Jaundice becomes evident on the second or third postoperative day, with bilirubin levels (mainly levels of conjugated bilirubin) peaking by the tenth day. Serum Alk. Ph. concentration may be elevated up to tenfold, but AST level is only mildly elevated. Hepatitis, choledocholithiasis, and hepatic infarct are unlikely diagnoses in the absence of abdominal tenderness, fever, or a significant rise in AST levels. The incubation period of posttransfusion hepatitis is 7 weeks, making this diagnosis unlikely.

A 6 y/o boy is brought by his mother because of a "red rash" that she noticed today. She says that 3 days ago he had a cough, runny nose, and fever that responded to ibuprofen. T=37 C (98.6 F) and he has a normal P/E with the exception of an erythematous, blanching macular rash on his legs. You diagnose him with a viral exanthem and advise the mother to encourage the child to drink liquids and to use ibuprofen as needed for fever. One week later, the mother brings the child back to the office and reports that the rash has "changed", he has developed colicky abdominal pain several times per day, and he is complaining of left knee pain. V/S: T=37.2 C (99 F), BP=100/65 mm Hg, PR=100/min, and RR=15/min. P/E reveals a well-appearing child with palpable purpura of both lower extremities, normal neck examination, clear lungs, and a soft, non-tender abdomen. His left knee is painful on flexion, but it is not erythematous or warm, and there does not seem to be an effusion. His gait is normal. The most appropriate study at this time is :
A. arthrocentesis
B. colonoscopy
C. cultures of blood, urine, and cerebrospinal fluid
D. echocardiography
E. urinalysis
The correct answer is E.
This patient most likely has Henoch-Schonlein purpura (HSP), a small-vessel vasculitis seen most commonly in children between the ages of 2 and 8. The child's preceding upper respiratory tract infection, low-grade fever, and arthralgias are all common elements of this disease. The typical rash of HSP is an evanescent, erythematous, macular rash on the lower extremities that progresses over the course of days to petechiae and palpable purpura. These change in color from red to purple to brown before eventually fading, normally over the course of weeks. HSP is an IgA-mediated autoimmune vasculitis, which can cause tissue damage as a result of immune complex formation. Deposition of these immune complexes in the kidneys can lead to nephritis, which is the leading cause of permanent sequelae from HSP. End-stage renal disease is an uncommon but possible outcome. It is important to perform frequent urinalyses for early detection of kidney involvement.

A 5 y/o boy is admitted to the hospital because of his increasing irritability and fever. The mother reports that the child has been having upper respiratory symptoms for the past week. In the last few days, the child has been constantly rubbing his left ear and has been increasingly irritable. The patient has had multiple ear infections in the past, that were treated with oral antibiotics. Following recurrent episodes of these ear infections, the child was advised to take a prophylactic, single dose of amoxicillin at bedtime. The child has been taking these antibiotics regularly for the past 3 months. On examination, the child is found to have a fever of 38.8 C (101.8 F). Examination of the right ear does not reveal any abnormalities. The examination of the left ear is uncomfortable, but the external auditory meatus appears normal. The tympanic membrane is examined after the removal of the cerumen and is noted to be hyperemic, bulging with indistinct anatomical landmarks. Light reflex is diminished and there is limited mobility on pneumatic insufflations. Some amount of middle ear effusion is also noticed. The most appropriate next step in the management is to
A. advise a tympanostomy tube placement
B. continue antibiotic prophylaxis with amoxicillin
C. prescribe a 10-day course of oral antibiotics
D. recommend decongestants, along with oral antibiotics
E. start intravenous antibiotic therapy
The correct answer is A.
Referrals for discussion of a tympanostomy tube placement should be considered if there is chronic bilateral effusion for more than 3 months in duration, unilateral effusion for more than 3 months in duration, language development delay, hearing loss of more than 20 decibels, or failure of antibiotic prophylaxis. This particular child has a history of recurrent acute otitis media treated with antibiotic prophylaxis. Failure of antibiotic prophylaxis requires tympanostomy tube placement.

An 8 mo/o infant is braught because of constipation. The father, a "stay-at-home dad," tells you that she has been having 1 bowel movement every 3-4 days, and that the stool is always very hard. He says that she is doing very well otherwise; she is a very happy and easy little girl. She is fed primarily infant formula and he is starting to introduce solid foods. He says that he is concerned because he remembers always having to change "very dirty" diapers for both of his other children, at least twice a day. Physical examination is unremarkable. A rectal examination shows guaiac negative brown stool. The most appropriate next step is to:
A. advise him to give her mineral oil 3 times a day until she is "regular"
B. advise him to give her prune juice or pear juice
C. determine thyroid-stimulating hormone levels
D. order a barium enema
E. order rectal manometry and a rectal biopsy
F. reassure him that all infants have different bowel habits
The correct answer is B.
Constipation is a common problem in formula-fed infants, and it is best treated by increasing the amount of fluids in the diet, especially with fruit juices that contain sorbitol, such as prune and pear, which help to relieve constipation. It is often caused by a diet that is too low in fluids or deficient of bulk.

A 7 day/o boy who is the product of an uncomplicated gestation is brought to the physician because of hypospadias. The baby is otherwise healthy, and is urinating without any difficulty. On physical examination, vital signs are stable, lungs are clear and the heart is beating at a regular rate. The only abnormal physical finding is the hypospadias. U/A is negative for infection. Which of the following is the most appropriate next step?
A. Measuring serum creatinine level
B. Schedule a renal ultrasound
C. Obtain an IVP
D. Cystography
E. Performing a circumcision

The correct answer is B.
Children with hypospadias are prone to urinary tract infections and other urinary tract anomalies. They require careful evaluation. A renal ultrasound is a safe way of diagnosing neonatal urinary tract pathology.

A 4 y/o old boy falls from the jungle gym at preschool. He sustains minor abrasions and contusions, and is taken care of by the school nurse. His parents take him that same afternoon to his regular pediatrician, P/E is unremarkable, his Hgb=14 g/dL, and U.A shows microhematuria. Which of the following is the most appropriate next step in management?
A. CT scan of the abdomen and pelvis
B. Reassure the parents that microhematuria from minor trauma will resolve spontaneously
C. Serial hemoglobin and hematocrit determinations
D. Urologic workup, starting with a sonogram
E. Retrograde ureterogram and cystogram

Answer is D.
Microhematuria after trivial trauma in children may be a sign of a congenital anomaly that makes the urinary tract unusually vulnerable. So work up is necessary. The first, noninvasive test should be the sonogram.

A 5 wk/o infant is brought for a 4 wk hx of noisy breathing that has not improved. She has otherwise been healthy except for a current URI for the past 4 days, which according to the parents, has worsened the noisy breathing. On P/E, she has inspiratory stridor. The noisy breathing improves when the infant is asleep. Which of the following is the most likely diagnosis?
A. Bronchoalveolar carcinoma
B. Foreign object obstruction
C. Laryngomalacia
D. Bacterial pneumonia
E. Tuberculosis

The correct answer is C.
The patient has stridor on examination which is an inspiratory obstruction that is sensitive to airflow changes. In children, the most common cause of stridor is laryngomalacia.

A 5 y/o boy develops a headache, cough, myalgia and a fever. He has been a healthy child with all immunizations up to date. He is given a decongestant and an aspirin for his symptoms with some relief. However, 4 days later, he is brought back by his parents because of persistent vomiting and irritability. On P/E, he is found to be semicomatose, becoming combative on stimulation. Which of the following would confirm the Dx?
A. Serum ammonia
B. Serum BUN
C. Serum calcium
D. Serum opiate level
E. Serum Na

The correct answer is A.
The child is presenting with symptoms of Reye syndrome, which is an acute encephalopathy associated with high ammonia levels. It most commonly occurs in young children after a viral illness. Administration of aspirin increases the risk of developing this disorder. The vomiting is characteristic.

Answer is D- intracranial hemorrhage
The level of serum sodium in this patient is 170 mEq/L. Infants who have hypernatremic dehydration are irritable and lethargic, and have a high-pitched cry. This type of dehydration results from a greater loss of hypotonic fluid than sodium and accounts for about 15% cases of dehydration. Because the patient has no history of diarrhea or vomiting, the hypernatremia may be due to inadequate supply of mother's milk that does not match the insensible water loss. Another cause can be the high concentration of sodium in mothers milk. Generally, after the child's birth, sodium in the colostrum decreases from its highest level to its lowest level by the fourth week. However, some mothers continue to excrete high sodium in their milk and can potentially cause recurrent hypernatremia and in some case intracranial hemorrhage in the infant.

Answer is 5. foreign body aspiration
Foreign body aspiration is the most common cause of recurrent pneumonia in an otherwise healthy 3 yo child. Becoz of the lung's anatomy,the rt.side is more common for aspiration.

A 4 mo/o white male is braught for his well-child visit. Both his father and his teenage brother have idiopathic epilepsy, which began during early childhood. Six hrs after the infant's 2-month DTaP he developed a fever of 39.5° C (103.1° F) rectally. His parents are concerned about the safety of further DTP immunization. Which one of the following is the best approach to DTaP immunization at this visit?

Answer is a.
False assumptions regarding contraindications often result in the needless deferment of indicated immunizations. The list of contraindications and precautions for DTaP immunization does not include a previous febrile reaction unless the fever was greater than 105° F, nor does it include a family history of seizures.

14 y/o girl presents with trouble concentrating at school just three months after witnessing her best friend being shot to death by another classmate. Ever since that "awful day" she has been very "sad" and withdrawn, often sitting on her bed, staring at the wall "for hours." She has frequent crying spells and refuses to play with friends or participate in her normal after-school activities. Her appetite has "dwindled down to nothing" and she feels very guilty that she survived the shooting. On further questioning, she reluctantly admits that she has constant thoughts of "joining her friend." She did not receive any counseling after the incident.
*** What’s the most likely Dx?
A. adjustment disorder
B. brief psychotic disorder
C. dysthymic disorder
D. major depressive disorder
E. normal grief
F. PTSD
*** What’s the most important q to ask at this time?
A. "Are you hearing voices?"
B. "Do you have any friends that you feel comfortable talking to at school?"
C. "Do you wear a helmet when you ride your bicycle?"
D. "Can you describe your typical weekly alcohol intake?"
E. "Have you thought of the means by which you can 'join your friend'?"

1- The correct answer is D. This patient most likely has major depressive disorder. To meet the criteria for this disorder a patient must exhibit a 2-week history of a distinct change in mood or a loss of interest or pleasure, along with at least 4 of the following: a decreased appetite and weight loss, difficulty sleeping, psychomotor retardation or agitation, fatigue, feelings of worthlessness or guilt, an inability to concentrate, and suicidal ideation. The symptoms must cause functional impairment.
2- The correct answer is E. Since she has already told you that she has suicidal ideation ("joining her friend"), it is very important to ask if she has "thought of the means by which" she can "join her friend" or has made any preparatory actions.

A 64 y/o married man has been diagnosed to be HIV positive. He comes in to the office to discuss the results and begs you not to tell his wife, who is also your patient. He says that hearing what he has been in involved in "will kill her." You remind him that HIV may also "kill her." The most appropriate first step is to:
A. contact his wife anonymously and tell her that she has been exposed to HIV
B. contact the appropriate government health agency and report your findings
C. promise him that as his doctor you will respect his privacy and maintain confidentiality
D. promise him that you will keep the results confidential if he agrees to use condoms with his wife
E. try to persuade him to voluntarily discuss the issue with his wife
The correct answer is E. Physicians must violate confidentiality and warn third persons about the danger of HIV infection if the patient is unwilling to inform the person himself. Before informing third parties, the physician should try to do everything possible to persuade the patient to voluntarily discuss the issue with their partner. If the physician believes that an individual may really be saved from a deadly infection, confidentiality should be violated.

A 4 y/o boy presents with fever, irritability, and erythema of the hands and feet for the past week. His mother has been giving him aspirin to reduce his temperature. P/E on admission showed a T=39.7 C (103.4 F), bilateral conjunctival injection, an enlarged right-sided cervical lymph node (1.8-cm), fissured lips, a red tongue with red papillae, pharyngeal hyperemia, erythematous and edematous palms and soles, and a confluent, blanching erythematous rash on the trunk. IV fluids were started, the aspirin therapy was continued. Laboratory studies show ESR= 28mm/h Plt= 490,000/mm3. The patient is extremely uncomfortable and now shows desquamation of the fingers and toes. The most appropriate therapy at this time is:
A. corticosteroids
B. ibuprofen
C. intravenous gammaglobulin
D. oxacillin
E. penicillin V
The correct answer is C. This patient most likely has Kawasaki disease, which is treated with aspirin and intravenous gammaglobulin. The disease is characterized by a high fever for longer than 5 days, bilateral conjunctival injection, fissured lips, a "strawberry tongue", mucosal change in the oral pharynx, erythematous and edematous palms and soles with desquamation, a polymorphous rash, cervical lymphadenopathy, an elevated erythrocyte sedimentation rate, and thrombocytosis. The most important complication is coronary artery aneurysms, which may be prevented by early treatment with aspirin and intravenous gammaglobulin. An echocardiogram is necessary to evaluate cardiac involvement.

47 y/o woman with a Hx of similar attacks of epigastric abdominal pain in the past was admitted to the hospital with a Dx of gallstone pancreatitis. She was NPO and IV fluid started. On the evening of admission day, the patient is noted to have T=103.4 F. Her BP & HR are within normal range. Her abdomen is diffusely tender to palpation with guarding. What’s the most appropriate management at this time?
A. draw blood cultures and await results
B. draw blood cultures and initiate ampicillin, gentamicin, and metronidazole therapy
C. draw blood, urine, and sputum cultures and await results
D. obtain an urgent abdominal CT scan
E. start ampicillin, gentamicin, and metronidazole therapy
The correct answer is B. The most appropriate management at this time is to draw blood cultures and initiate ampicillin, gentamicin, and metronidazole therapy. Intravenous antibiotics are only indicated if there is evidence of pancreatic necrosis or if the patient develops a fever after the diagnosis of pancreatitis is made. There is a substantial amount of clinical literature validating this approach to treating pancreatitis. The appropriate sequence of events is to draw blood cultures prior to initiating therapy in order to maximize chances of detecting an organism.

A 24 hour old male infant is noted to have some peculiar jerking movements of the right foot and arm. His axillary temperature an hour before was 36.2"C. The physical examination reveals no unusual findings except that he appears small and premature. His birth weight was 2,550 g. The mother's and infant' s history show that he was the second of twins born after 37 weeks' gestation, presented in transverse position and his heart rate had dropped to 80 per minute 10 minutes prior to birth, with documented fetal hypoxia. He had an Apgar score of 3 at 1 minute and 7 at 5 minutes. The mother had nausea and vomiting during pregnancy for which she was given vitamin B6. She had mild preeclampsia at delivery.
*** Which is the most likely diagnosis?
a) Brain tumor
b) Hypoxemia in utero and possibly during delivery
c) Cerebral trauma during delivery
d) Vitamin B6 dependency
e) None of the above
*** In the diagnostic work-up, you may obtain the following tests or procedures, EXCEPT:
a) CT scan of the head
b) Lumbar puncture for examination and culture of spinal fluid
c) Electroencephalography
d) Serology for toxoplasmosis
e) Blood levels of sugar and calcium
answers are B & D
Hypoxemia is the leading cause of seizures considering the history of drop in fetal heart rate and low Apgar score at 1 minute. Hypoglycemia, hypocalcemia, vitamin B6 dependency, and meningitis are possible causes of seizures but unlikely and should be ruled out. Some cerebral anomaly is possible. Incidence of congenital malformations is higher in twins than , in singletons, and central nervous system malformations lead all others in frequency. Brain tumors at this age are rare and usually present with recurrent vomiting and not with seizures.